Which statement accurately describes a Health Maintenance Organization plan regarding network usage and referrals?

• A. It offers the broadest out-of-network coverage
• B. It requires using in-network providers and referrals, with lower premiums
• C. It has no network restrictions
• D. It has no referrals and direct access to specialists

Answer: (B)

Health Maintenance Organization plans focus on a defined provider network and gatekeeping through a primary care physician. You generally must stay in-network for services, and to see a specialist you need a referral from your PCP. This structure helps control costs, which is why premiums and out-of-pocket costs are typically lower for in-network care. HMOs usually do not cover services obtained out of network except in emergencies. So the statement describing using in-network providers and requiring referrals while offering lower premiums accurately captures how HMOs operate. Other descriptions implying broad out-of-network coverage or no network restrictions don’t describe HMOs.