What should an agent have better explained to Doug, who enrolled in an HMO MA Plan and received a bill for out-of-network services?

The rationale for the correct answer lies in the foundational structure of Health Maintenance Organizations (HMOs), particularly regarding how they manage provider networks. An HMO plan provides coverage primarily for services rendered by contracted or network providers. This setup is designed to keep costs predictable and care coordinated within a defined network of providers.

When Doug enrolled in an HMO Medicare Advantage (MA) plan, it was crucial for him to understand that to maximize his benefits and minimize out-of-pocket expenses, he must seek care exclusively from these contracted providers. If he opts for out-of-network services, he may find himself responsible for the full cost of those services or face significantly higher out-of-pocket expenses, which is often a common point of confusion among members new to an HMO structure.

This understanding helps reinforce the importance of network adherence and the roles that network providers play in the coverage mechanism of the plan. This also clarifies that services from out-of-network providers typically are not covered unless in extraordinary situations, which aligns with the general operational principles of HMO plans.

The other options address common misconceptions but do not correctly reflect the fundamental requirement of using network providers in an HMO plan. Thus, emphasizing the necessity of receiving services from contracted network providers provides Doug with the crucial information he