Which plan typically requires referrals for specialist care?

Which plan typically requires referrals for specialist care?

• A. HMO
• B. PPO
• C. EPO
• D. POS

Answer: (A)

Gatekeeping by a primary care physician is the key concept. In an HMO, you choose a PCP who coordinates all of your care, and to see a specialist you typically need a referral from that PCP. This gatekeeper role helps keep care within the network and controls costs by ensuring specialist visits are appropriate and necessary. That referral requirement is what makes HMOs the plan that typically requires referrals for specialist care. In contrast, PPOs usually let you see a specialist directly without a referral (though costs rise if you go out of network). EPOs and POS plans have their own network and referral nuances, but the strongest link to needing referrals is the gatekeeper model of HMOs.

Gatekeeping by a primary care physician is the key concept. In an HMO, you choose a PCP who coordinates all of your care, and to see a specialist you typically need a referral from that PCP. This gatekeeper role helps keep care within the network and controls costs by ensuring specialist visits are appropriate and necessary. That referral requirement is what makes HMOs the plan that typically requires referrals for specialist care. In contrast, PPOs usually let you see a specialist directly without a referral (though costs rise if you go out of network). EPOs and POS plans have their own network and referral nuances, but the strongest link to needing referrals is the gatekeeper model of HMOs.