Referral
The PCP's authorization required by HMO and POS plans before a member may see a network specialist, without which specialist care is not covered.
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Practice This Concept
A health plan requires members to select a primary care physician, obtain a referral to see specialists within the network, but also covers out-of-network care at a lower benefit level when the member receives a referral. This combination of features best describes a:
Point-of-Service (POS) plan — A Point-of-Service (POS) plan is a managed care hybrid that combines features of an HMO and a PPO. Within the network, the POS plan works like an HMO: members must choose a primary care physician, and referrals are required before seeing a specialist or obtaining other covered care. Outside the network, the POS plan adds limited PPO-style flexibility, covering out-of-network services at a reduced benefit level when the member has obtained the proper referral. That combination of a gatekeeper and partial out-of-network access is the defining characteristic of a POS plan, so A correctly identifies the plan type.
National insurance concept
A member of a Point-of-Service (POS) health plan wants to see a specialist who is outside the plan's network. Under the typical POS structure, what must the member do first?
Obtain a referral from the primary care physician (gatekeeper) before seeing the out-of-network specialist — A POS plan is a managed care hybrid: like an HMO it requires the member to select a primary care physician who acts as a gatekeeper, and like a PPO it allows care outside the network. The tradeoff is that using an out-of-network specialist ordinarily requires a referral from the primary care physician, and out-of-network care carries higher cost-sharing. Because the gatekeeper-referral mechanism is preserved, the member must obtain that referral before the out-of-network visit.
National insurance concept
- Medical ExpenseA health plan requires members to select a primary care physician, obtain a referral to…
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- Medical ExpenseA Point-of-Service (POS) health plan is best described as:
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