Which plan is most likely to require referrals from a PCP to see specialists?

• A. PPO
• B. Self Pay
• C. TRICARE
• D. HMO

Answer: (D)

A gatekeeper model where a primary care physician coordinates care and controls access to specialists is what this item is testing. In an HMO, you select or are assigned a primary care physician who serves as your first contact for any health issue. To see a specialist, you generally need a referral from that PCP. This gatekeeper approach helps manage costs and ensures that specialist visits are medically appropriate, with coverage typically limited to in-network providers. Referrals and network rules are core features of HMOs, and out-of-network visits are usually not covered except in emergencies.

In contrast, a preferred provider organization (PPO) lets you see specialists without referrals, though you’ll save money by staying in-network. Self-pay isn’t an insurance plan at all—it involves paying out of pocket, so referral rules don’t apply. TRICARE plans vary by type, with some offering Prime-like structures that use referrals, but the classic, most consistent referral requirement across plans is found with HMOs.