Under an HMO, using out-of-network services generally results in what?

• A. The plan covers all costs regardless of network.
• B. The member typically pays the full cost for out-of-network services.
• C. The plan pays 50% of out-of-network costs.
• D. Out-of-network services are never allowed.

Answer: (B)

In an HMO, care is provided through a defined network of providers, and the plan is designed to pay most costs when you stay in-network. Out-of-network services are generally not covered, or are covered only at a minimal level, so you’re typically responsible for the full cost of those services. Emergencies are sometimes treated differently, but for routine care the usual outcome is paying the full price out-of-pocket when you go out-of-network. This is why the statement that the member typically pays the full cost for out-of-network services is the best fit.