Free Medical Plans Study Guide
Texas General Lines — Life, Accident, Health & HMO exam — Medical Plans.
The national Medical Plans guide covers plan types, cost sharing and the ACA. Texas tests HMO rules heavily, because the Life, Accident and Health exam includes HMOs. It also tests the state's health mandates. This guide covers both. Individual policy provisions and group continuation are in the Texas Individual A&H Provisions and Group Health guides.
HMOs (TIC Chapters 843 and 1271; 28 TAC Chapter 11)
Basics
- An HMO arranges for or provides health care to enrollees on a prepaid basis, usually through a network of contracted providers (843.002).
- An HMO agent needs the general life, accident and health license (4054.051).
- The evidence of coverage is the enrollee's contract. It must be filed with and approved by the Commissioner before use (28 TAC 11.501).
Contract terms (28 TAC 11.506)
- Grace period: at least 30 days, with coverage continuing.
- Cancellation: only for nonpayment or a reason allowed by rule, such as fraud (843.208).
- Cancellation for fraud or intentional misrepresentation needs at least 15 days' written notice.
- An HMO can never cancel for health-status reasons.
- Copayments: an option can't exceed 50% of the cost of the service. Annual copays are capped at 200% of the annual premium.
- Deductibles: HMOs generally can't charge them for in-network services, except in consumer choice plans.
- Enrollment statements are representations. One can be used in a contest only if it's in a signed application the subscriber received a copy of.
Provider access
- An assigned primary care physician must be in the zip code nearest the enrollee's home or job (843.315).
- The enrollee may reject the assignment at any time and pick another network doctor.
- If a needed service isn't available in the network, the HMO must cover out-of-network care at the in-network benefit level (28 TAC 11.1611). It processes the referral within 5 business days.
- Emergency care is covered, including out of network (1271.155).
Mandates and protections
| Topic | Texas rule |
|---|---|
| Newborns | Covered from birth. A plan may not limit a newborn's initial coverage before the 61st day after birth, and must cover congenital defects and required newborn screening tests (1367.003, as amended effective September 1, 2025). Coverage must be at least as broad as for other children (28 TAC 3.3403). |
| Mammography | Annual low-dose screening for women 35 and older (1356.005). |
| Diabetes | Equipment, supplies and self-management training (1358.054, 1358.055). |
| Chemical dependency | Group plans cover treatment on terms no less favorable than physical illness (1368.004, 1368.005). |
| HIV testing | Requires written consent on TDI's separate "Notice and Consent for HIV-Related Testing" form (28 TAC 21.704). An adverse decision needs two positive ELISA tests confirmed by a Western Blot (21.705). Questions about sexual orientation are prohibited. |
Common exam traps
- HMO grace period: 30 days. Fraud cancellation needs 15 days' notice.
- HMO copay caps: 50% of a service's cost, 200% of annual premium.
- An HMO primary care doctor must be in the nearest zip code, and the enrollee can switch at any time.
- Newborn initial coverage can't be limited before day 61.
- An HIV test needs separate written consent.
Practice Medical Plans questions All General Lines — Life, Accident, Health & HMO topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
