State RegulationsOH specificDifficulty 3/5
Which statement accurately distinguishes the primary care physician from the referral (specialty) physician in an HIC's gatekeeper structure?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
The gatekeeper structure under Ohio's HIC framework, governed by Ohio Revised Code Chapter 1751, assigns distinct roles: the primary care physician is the ongoing first contact who coordinates the member's overall care and initiates specialist referrals, while the referral (specialty) physician provides care for the specific condition for which the member was referred. Keeping these roles distinct is central to how the organized delivery system functions under Ohio Department of Insurance supervision.
Why the other options are wrong
- A) Reversing the roles describes the specialty physician performing the gatekeeper's function, which the structure does not contemplate.
- B) The roles are deliberately distinct — coordination belongs to the primary care physician, not to specialists.
- C) In a gatekeeper design the primary care physician initiates the referral; the specialist does not approve his or her own referrals.
Memory hook
PCP runs the map; the specialist visits only the destination that was referred.