PSI Ohio Insurance Practice Exam

What is true about health maintenance organizations (HMOs) in terms of insurance?

1. HMOs provide less coordinated care compared to PPOs.

2. HMOs generally require referrals to see specialists.

3. HMOs are typically less cost-effective than other plans.

4. HMOs cover out-of-network healthcare automatically.

The correct answer is: HMOs generally require referrals to see specialists.

Health Maintenance Organizations (HMOs) typically require referrals to specialists as a defining characteristic of their structure. When a patient is enrolled in an HMO, they usually have a primary care physician (PCP) who acts as a gatekeeper. This PCP is responsible for providing general health care and coordinating the patient's overall treatment. If a patient needs to see a specialist for additional care, the HMO requires that the PCP provide a referral to ensure that the specialist is part of the HMO network. This system helps manage costs and ensures that care is coordinated, which can lead to better health outcomes. The requirement for referrals is a key aspect that sets HMOs apart from other types of health insurance plans, such as Preferred Provider Organizations (PPOs), where members have more flexibility to see specialists without needing a referral. This emphasis on coordination through a primary care physician helps maintain a focused approach to patient care within the network, ultimately streamlining the process and potentially lowering healthcare costs for both the provider and the patient.