Georgia Navigator Practice Exam

How do Health Maintenance Organizations (HMOs) operate regarding specialists?

1. Members can see any specialist without referral

2. All specialists are covered outside of the network

3. A referral from a primary care provider is required

4. They do not have any specialists on their panel

The correct answer is: A referral from a primary care provider is required

Health Maintenance Organizations (HMOs) have a specific structure designed to manage costs while providing coverage to their members. One of the key features of HMOs is that they require members to obtain a referral from their primary care provider (PCP) before seeing a specialist. This system ensures that the PCP is involved in coordinating care, maintaining oversight of the patient's treatment, and managing resources efficiently. By requiring referrals, HMOs can control costs and ensure that members are receiving appropriate specialty care based on their specific health needs. This process helps to prevent unnecessary visits to specialists, which can lead to higher costs both for the insurance company and the members themselves. Through this coordinated approach, HMOs aim to ensure that members receive both preventive and necessary medical services in a structured manner.