An HMO member suffers a heart attack while traveling outside the HMO's service area and is treated at a local emergency room. The HMO must:

Why C is correct

Managed care plans such as HMOs must cover emergency medical care whenever and wherever the member needs it, including outside the plan's service area. Emergency services are judged under the prudent layperson standard: a symptom severe enough that a reasonable person would believe immediate care is needed triggers coverage. An HMO cannot require prior authorization for a true emergency, and a member who receives emergency treatment while traveling is entitled to coverage for the stabilization and treatment of that emergency. Emergency care is defined by the prudent layperson standard: a condition with acute symptoms of sufficient severity that a reasonable person would expect serious impairment or harm. Plans must cover such services without prior authorization, although reasonable cost sharing and balance-billing limits still apply.

Why the other options are wrong

• D) Denying emergency care because the member was out of area would violate the obligation to cover emergencies; out-of-area emergencies are covered. Plans cannot condition emergency coverage on staying inside the service area; the prudent layperson standard protects members who are far from home when a true emergency occurs.
• A) Coverage extends to the full emergency episode, including emergency room treatment, stabilization, and related services, not merely ambulance transport. The emergency obligation covers the emergency room evaluation and treatment themselves, not merely transport, so limiting coverage to the ambulance misdescribes the rule.
• B) Requiring a member in the middle of a medical emergency to travel home is unreasonable and not permitted; emergency care is covered where it occurs. Forcing the member to return home first would make emergency care unavailable precisely when it is needed most, and prior-approval requirements for emergencies are prohibited.

Memory hook

Emergencies ignore zip codes: real emergencies are covered anywhere, no gatekeeper stamp required.