FPGEE for National Association of Boards of Pharmacy (NABP) Practice Exam

Which health plan requires a referral for specialist consultations?

1. PPO

2. POS

3. HMO

4. PSO

The correct answer is: HMO

The health plan that requires a referral for specialist consultations is typically the Health Maintenance Organization (HMO). HMOs focus on providing healthcare services through a network of providers and require members to choose a primary care physician (PCP). This PCP acts as a gatekeeper for healthcare services, meaning that patients must see their PCP for any health issue and obtain a referral before accessing specialty care. This system encourages coordinated care and often has lower out-of-pocket costs for members if they stay within the network. In contrast, Preferred Provider Organizations (PPOs) offer more flexibility in choosing healthcare providers and do not generally require referrals for specialist consultations, allowing members to see any participating specialist directly. Point of Service (POS) plans blend features of HMO and PPO plans, where referrals are needed to access specialists, but they also allow the option to seek care outside of the network, albeit at higher costs. Lastly, Patient-centered Medical Homes (PSOs) focus more on coordinated care and may streamline access to specialists, but they do not typically enforce a referral requirement in the same way that HMOs do. Thus, the requirement of a referral for specialists is a defining characteristic of HMO plans, making it the correct choice.