Illinois Health Insurance Practice Exam

If an HMO insured obtains service from a hospital or physician service provider that is not in the network, what happens?

1. Full coverage

2. Coverage with limitations

3. No coverage except in emergencies

4. Coverage with high copays

The correct answer is: No coverage except in emergencies

When an HMO member receives services from a hospital or provider outside of the HMO's network, the typical outcome is no coverage except in emergencies. This policy is grounded in the structure of Health Maintenance Organizations (HMOs), which usually require beneficiaries to use a network of designated providers to receive full benefits. If the insured seeks services from a non-network provider without a valid emergency situation, the HMO will not cover those costs at all, placing the financial responsibility solely on the insured. This strict adherence to network utilization is designed to control costs and encourage the use of preventive care through designated providers. In emergency situations, however, HMOs often have provisions that allow for coverage even if the provider is outside the network to ensure the immediate care needed is provided without delay. This ensures that patients are not penalized for seeking urgent care in circumstances where it may not be feasible to reach an in-network provider.