Certified Medical Administrative Assistants (CMAA) Practice Exam

What type of plan generally requires referrals to see a specialist?

1. Health Maintenance Organization (HMO)

2. Preferred Provider Organization (PPO)

3. Indemnity Plan

4. Point of Service (POS) plan

The correct answer is: Health Maintenance Organization (HMO)

The Health Maintenance Organization (HMO) plan is designed to require members to choose a primary care physician (PCP) who acts as a central point for managing their healthcare needs. When a patient needs to see a specialist, they typically must obtain a referral from their PCP before proceeding with that visit. This system is in place to ensure coordinated care, manage costs, and streamline the patient's healthcare experience. Moreover, the referral process helps the primary care physician maintain oversight of the patient's overall health strategy and promotes preventative care. In contrast, other types of plans like the Preferred Provider Organization (PPO) and the Indemnity Plan provide greater flexibility. With PPOs, patients can see specialists without needing a referral. Indemnity Plans allow patients to see any doctor or specialist they wish without prior authorization or a referral. The Point of Service (POS) plan, while somewhat similar to an HMO, allows for referrals but gives the option to see out-of-network providers at a higher cost. In essence, the referral requirement is a defining characteristic of HMO plans, distinguishing them from other plan types that offer more freedom in accessing specialist care.