Which plan requires use of network providers with no coverage outside except emergencies, and uses a gatekeeper primary care physician?

Which plan requires use of network providers with no coverage outside except emergencies, and uses a gatekeeper primary care physician?

• A. EPO
• B. POS
• C. PPO
• D. HMO

Answer: (D)

Health Maintenance Organization plans operate with a fixed network and require you to choose a primary care physician who coordinates all your care. You must stay in-network for non-emergency services, and you need referrals from that gatekeeper to see any specialists. Because of this gatekeeper system and the network restriction, there is typically no coverage for care received outside the network except in emergencies, which helps keep costs down for both the plan and the member. Other plan types don’t fit this description because they either don’t rely on a gatekeeper in the same way or they allow some out-of-network care. An Exclusive Provider Organization also uses a network but generally doesn’t require a gatekeeper or referrals. A Point-of-Service plan combines gatekeeping with some out-of-network coverage. A Preferred Provider Organization offers more freedom, with in-network and out-of-network options and usually no gatekeeper.

Health Maintenance Organization plans operate with a fixed network and require you to choose a primary care physician who coordinates all your care. You must stay in-network for non-emergency services, and you need referrals from that gatekeeper to see any specialists. Because of this gatekeeper system and the network restriction, there is typically no coverage for care received outside the network except in emergencies, which helps keep costs down for both the plan and the member.

Other plan types don’t fit this description because they either don’t rely on a gatekeeper in the same way or they allow some out-of-network care. An Exclusive Provider Organization also uses a network but generally doesn’t require a gatekeeper or referrals. A Point-of-Service plan combines gatekeeping with some out-of-network coverage. A Preferred Provider Organization offers more freedom, with in-network and out-of-network options and usually no gatekeeper.