Which statement is true about Health Maintenance Organization (HMO) plans?

• A. Members may receive care from any provider without referrals.
• B. Members receive all services through predetermined providers with PCP referrals; cannot go outside plan except in emergencies.
• C. There is no cap on visits per diagnosis.
• D. The plan pays on a fee-for-service basis with no capitation.

Answer: (B)

Health Maintenance Organization plans use a managed care approach with a fixed network and gatekeeping by a primary care physician. You pick a PCP who coordinates your care, and you need referrals from that PCP to see specialists or receive most services. All covered care is provided through the plan’s predetermined network, and going outside that plan is generally not covered except in emergencies or with prior authorization. This structure is why the statement about coordinated, PCP-directed care within a network best describes an HMO. In contrast, plans that let you see any provider without referrals reflect other models, and HMOs typically rely on capitation payments to providers rather than traditional fee-for-service (which aligns with the focus on cost control and utilization management).