Which plan generally requires primary care physicians and referrals to see specialists?

Which plan generally requires primary care physicians and referrals to see specialists?

• A. PPO
• B. HMO
• C. HDHP
• D. EPO

Answer: (B)

Access to specialists is controlled by how a plan handles gatekeeping. In an HMO, you choose a primary care physician who coordinates all your care. You typically need a referral from that PCP to see any specialist, and you usually stay within the plan’s network. This setup is designed to manage costs and ensure coordinated, preventive care. Other plans work differently: a PPO lets you visit specialists without a referral and often covers some out-of-network care, though at higher costs; a high-deductible health plan is defined by a large deductible and an HSA rather than a referral structure; an EPO generally requires you to use in-network providers and may or may not require referrals, depending on the plan. Because its defining feature is the PCP gatekeeper and required referrals for specialists, this plan aligns with the scenario described.

Access to specialists is controlled by how a plan handles gatekeeping. In an HMO, you choose a primary care physician who coordinates all your care. You typically need a referral from that PCP to see any specialist, and you usually stay within the plan’s network. This setup is designed to manage costs and ensure coordinated, preventive care.

Other plans work differently: a PPO lets you visit specialists without a referral and often covers some out-of-network care, though at higher costs; a high-deductible health plan is defined by a large deductible and an HSA rather than a referral structure; an EPO generally requires you to use in-network providers and may or may not require referrals, depending on the plan. Because its defining feature is the PCP gatekeeper and required referrals for specialists, this plan aligns with the scenario described.