Under TIC 843.002, which individual is an "enrollee" of a health maintenance organization?

Why A is correct

Under TIC 843.002, "enrollee" means an individual who is enrolled in a health care plan and includes covered dependents. The term is not limited to the subscriber who signed up, so a covered spouse and child are enrollees with the same statutory rights — including the complaint and appeal rights in Chapter 843 — as the subscriber. A person who is only eligible and interested is a "prospective enrollee" under the same section, and merely residing inside the service area does not enroll anyone in a plan.

Why the other options are wrong

• B) An individual who is eligible for coverage and has expressed an interest is a "prospective enrollee" under TIC 843.002, not an enrollee.
• C) Residing within the service area is a common eligibility condition for coverage but does not by itself enroll anyone in a health care plan.
• D) The subscriber is an enrollee, but the definition expressly includes covered dependents, so it is not limited to the person who signed the form.

Memory hook

Enrollee means enrolled, and dependents count too.

Why A is correct

Under TIC 843.002, an enrollee is a person entitled to receive health care services under an evidence of coverage issued by the HMO. The term is not limited to the employee who signs up; covered dependents who are entitled to services are enrollees as well. This matters because the HMO's delivery, notice and complaint-handling obligations run to each enrollee, not merely to the group contract holder.

Why the other options are wrong

• B) A contracted physician is a provider under Chapter 843, not an enrollee.
• C) A TDI examiner is a regulator and has no entitlement to receive services under the evidence of coverage.
• D) The employer purchasing the coverage is the group contract holder, not the enrollee.

Memory hook

Enrollee = the one entitled to be treated, not the one doing the treating or paying for it.