State RegulationsTX specificDifficulty 1/5
In Texas HMO terminology, which term describes the physician, hospital or other person or institution that contracts with the HMO to furnish health care services to enrollees?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under TIC 843.002, a provider is a physician, hospital or other person or institution that is licensed or otherwise authorized to furnish health care services and does so for enrollees under arrangements with the HMO. Keeping providers separate from enrollees matters throughout Chapter 843: the HMO's network, referral and claim payment rules govern its relationship with providers, while the evidence of coverage governs what the HMO owes the enrollee.
Why the other options are wrong
- A) A solicitor is a licensing term for a person who solicits insurance, not for a health care provider.
- B) The enrollee is the person entitled to receive services, not the party furnishing them.
- C) The contract holder is the employer or group that purchases the coverage.
Memory hook
Providers give the care; enrollees get the care; the contract holder buys it.