Which plan requires a PCP referral for most services?

Which plan requires a PCP referral for most services?

• A. PPO
• B. HMO
• C. HDHP
• D. EPO

Answer: (B)

Many health plans use a gatekeeper model where a primary care physician coordinates your care and must authorize referrals to specialists. This gatekeeping is characteristic of an HMO. In an HMO, you typically pick a PCP who manages your overall care, and you’ll usually need a referral from that PCP to see any specialist (except in emergencies or for certain preventive services). This helps control costs and ensures appropriate use of specialty services. In contrast, a PPO lets you see specialists without a referral, though staying in-network lowers costs. An EPO usually requires you to stay in-network and generally doesn’t require referrals for specialists. A high-deductible health plan (HDHP) defines the deductible and how you pay for care, but referral requirements aren’t the defining feature.

Many health plans use a gatekeeper model where a primary care physician coordinates your care and must authorize referrals to specialists. This gatekeeping is characteristic of an HMO. In an HMO, you typically pick a PCP who manages your overall care, and you’ll usually need a referral from that PCP to see any specialist (except in emergencies or for certain preventive services). This helps control costs and ensures appropriate use of specialty services.

In contrast, a PPO lets you see specialists without a referral, though staying in-network lowers costs. An EPO usually requires you to stay in-network and generally doesn’t require referrals for specialists. A high-deductible health plan (HDHP) defines the deductible and how you pay for care, but referral requirements aren’t the defining feature.