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What type of health insurance plan typically requires a referral to see a specialist?

  1. Indemnity plan

  2. Preferred provider organization (PPO)

  3. Health maintenance organization (HMO)

  4. Point of service (POS) plan

The correct answer is: Health maintenance organization (HMO)

A Health Maintenance Organization (HMO) plan typically requires members to obtain a referral from their primary care physician (PCP) in order to see a specialist. This structure is designed to manage patient care and costs more effectively. Under an HMO, the emphasis is on coordinated care where the primary care physician serves as the gatekeeper to specialist services. This means that patients often need prior authorization from their PCP to access specialist services, ensuring that the necessary and appropriate care is provided while also controlling healthcare expenses. In contrast, other types of plans, such as indemnity plans, Preferred Provider Organizations (PPOs), and Point of Service (POS) plans, offer a greater degree of flexibility. For instance, PPOs allow members to see specialists without referrals and often do not require a primary care doctor to coordinate care. POS plans may combine elements of both HMOs and PPOs, permitting referrals but also allowing members to seek specialty care without prior approval. Indemnity plans usually provide the least structured type of care, allowing patients to see any healthcare provider without referrals, making them more flexible than HMOs concerning specialist visits.