The purpose of this webpage is to help you learn about an evidence of coverage that is issued by a health maintenance organization (HMO).
The document that a Texas-licensed HMO uses to describe the services and benefits to which a covered person is entitled is called an "evidence of coverage" (EOC). A HMO is required to cover certain services and benefits, depending on the type of HMO it is. There are three types of HMOs:
- Basic Service (offering a basic health care services plan - 28 TAC §11.508(a))
- Limited Service (offering a mental health/chemical dependency or a long term care plan)
- Single Service (offering, e.g., a dental-only plan or a vision-only plan)
The HMO's EOC must be clear and complete and must include information about:
- Benefits & Limitations
- Obtaining Services
- Complaints & Appeals
You should read your EOC thoroughly and become as familiar as possible with the information contained in it because it explains how the HMO plan works. When you have questions about what your HMO covers or how to obtain covered services, you should refer to your EOC for guidance. If, after reviewing the EOC, you still have questions, you may contact your HMO using the toll-free telephone number at the front of your EOC and ask your HMO for assistance.
You are entitled to your HMO's EOC. Some HMOs provide copies of the EOC to the employer for distribution to their employees and some HMOs issue the EOC to covered persons themselves. Either way, you are entitled to your HMO's EOC, so be sure to ask your HMO representative or your employer for a copy of the EOC if you do not already have one.