Under a typical HMO plan, which statement is correct regarding emergency medical care?

Why A is correct

HMOs require members to receive care within the network, but that rule does not apply to emergencies. Under the prudent layperson standard used by managed care plans, emergency services are covered even when rendered by an out-of-network hospital or physician, because a person experiencing a medical emergency cannot reasonably be expected to select an in-network facility. The gatekeeper referral requirement is waived for emergencies; the member simply pays the applicable copay or coinsurance, and follow-up care is then routed back into the network.

Why the other options are wrong

• B) Requiring a referral for an emergency would defeat the purpose of emergency coverage; HMOs expressly waive the gatekeeper requirement for emergency services.
• C) Out-of-network emergency care is a standard covered benefit under HMO plans; the network limitation yields to the reality of a medical emergency.
• D) The HMO pays the emergency claim (subject to the member's cost-sharing); there is no requirement to pay the full bill and seek state reimbursement.

Memory hook

Emergencies break every HMO rule. No referral needed, network walls fall, coverage follows the ambulance.