Do HMOs generally cover out-of-network services?

• A. Yes, fully covered
• B. Yes, with higher cost
• C. Only in emergencies
• D. No, typically not covered

Answer: (D)

HMOs operate with a fixed network of doctors and facilities, and benefits are tied to staying in that network. You typically choose a primary care physician who coordinates your care and requires referrals to specialists. Because the plan contracts only with in-network providers, services from out-of-network clinicians are usually not covered (or are covered at a much higher cost to you). That’s why, in general, out-of-network services aren’t covered under HMOs. Emergencies are commonly covered even if the care is out of network, but that’s an exception rather than the rule, so the overall pattern is no coverage outside the network.