Which statement describes network provider services in an HMO plan?

• A. PPO plans generally cover only network services.
• B. Health Maintenance Organization (HMO) Plans generally cover only network services. In most cases, members pay the full cost of any out-of-network services received, with a few important exceptions.
• C. Medicare Advantage plans pay for out-of-network services equally to in-network.
• D. All plans cover out-of-network services with no restrictions.

Answer: (B)

In an HMO, coverage is built around a network of contracted providers. You typically use a gatekeeper (a primary care physician) and need referrals to see specialists, and care is generally provided within the plan’s network. Because those network arrangements control costs, the plan mostly pays for network services and does not cover out-of-network care, with a few important exceptions such as emergencies or pre-approved services allowed by the plan. This makes the statement about HMOs covering only network services the best description.

Other plans work differently: PPOs usually cover both in-network and out-of-network care, though at higher costs out-of-network; Medicare Advantage plans vary and don’t universally pay the same for out-of-network as for in-network; and no major plan covers out-of-network services with no restrictions.