HMO won't pay for coverage out of state

[ninalou]

What is the name of your state? New Mexico (state in question)

I am posting this message for a friend who lives in New Mexico. He was recently diagnosed with an operable brain tumor. His neurologist suggested he go to a hospital in New York for surgery because the specialists at the hospital in NY are far superior and he stands a better chance for recovery. His HMO is now telling him they will only pay for medical care in the state of New Mexico.

Can an insurance company do this? What if one was traveling on vacation and fell ill? Are they telling us we can't go on vacation or visit relatives out of state because if we get sick or have an accident we won't be covered?

Please advise.

Thank you!

 

[somarco]

When you have coverage through an HMO, they direct your care. If you elect to go outside their service area for care, you pay the bills. Exceptions are made for things such as a life threatening emergency. This situation seems to fall under the general care of the HMO agreement.

 

[cbg]

This is not only legal, it is not even an uncommon restriction for an HMO. The whole point of an HMO is to keep care within the network.

Most HMO's will pay for EMERGENCY care outside the network, but your friend's situation does not meet the definition of emergency OON treatment.

 

[ninalou]

Thank you

Thank you both for the information. I will relay this back to my friend.

All I have to say is, I am so glad I DON'T have an HMO for my insurance!