Which plan requires staying within a network and obtaining referrals?

Which plan requires staying within a network and obtaining referrals?

• A. PPO
• B. HMO
• C. POS
• D. EPO

Answer: (B)

This question tests how different health plans control access to care through network rules and referral requirements. The plan that requires staying within a network and getting referrals is the HMO. In an HMO, you typically choose a primary care physician who coordinates all care, and you must receive referrals from that PCP to see specialists. Coverage is limited to providers within the network, with little to no coverage for out-of-network care except in emergencies. This setup emphasizes coordinated, cost-controlled care. PPO plans, by contrast, let you see both in-network and out-of-network providers, usually with higher costs if you go out of network and often without needing referrals to see specialists. POS plans blend features: you have a primary care doctor and referrals for networked specialists, but you can go outside the network at higher costs. EPO plans require using in-network providers and generally do not cover out-of-network care, but they typically do not require referrals to see specialists.

This question tests how different health plans control access to care through network rules and referral requirements. The plan that requires staying within a network and getting referrals is the HMO. In an HMO, you typically choose a primary care physician who coordinates all care, and you must receive referrals from that PCP to see specialists. Coverage is limited to providers within the network, with little to no coverage for out-of-network care except in emergencies. This setup emphasizes coordinated, cost-controlled care.

PPO plans, by contrast, let you see both in-network and out-of-network providers, usually with higher costs if you go out of network and often without needing referrals to see specialists. POS plans blend features: you have a primary care doctor and referrals for networked specialists, but you can go outside the network at higher costs. EPO plans require using in-network providers and generally do not cover out-of-network care, but they typically do not require referrals to see specialists.