When a Texas HMO assigns a primary care physician to an enrollee who did not select one, which location requirement applies to the assigned physician under TIC 843.315?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under TIC 843.315, if an enrollee does not select a primary care physician or provider at the time of application or enrollment, the HMO may assign one, and under Subsection (e) a primary care physician or provider assigned in that way must be located within the ZIP code nearest the enrollee's residence or place of employment. The location limit keeps a default assignment convenient for the enrollee: the HMO cannot park unassigned enrollees with a physician located wherever the HMO prefers. The statute also requires the assignment to result in a fair and equal distribution of enrollees among the network's primary care physicians and providers.
Why the other options are wrong
- A) Thirty miles is not the statutory measure; the statute speaks in terms of the nearest ZIP code, not a fixed mileage radius.
- C) The service area as a whole is too broad; the assigned physician must be within the nearest ZIP code, not merely somewhere in the approved territory.
- D) A county-office rule appears nowhere in the statute; proximity is measured by the nearest ZIP code to the residence or place of employment.
Memory hook
Assigned doctors live in the nearest ZIP code to home or work.