Texas General Lines — Life, Accident, Health and HMOHealth InsuranceMedium
Which of the following is NOT a characteristic of a Health Maintenance Organization (HMO)?
- AServices are usually provided on a prepaid basis.
- BEmphasis on preventative care.
- CMembers can receive care from out-of-network providers without a referral and still receive full benefits.
- DMembers are typically required to select a Primary Care Physician (PCP).
Show answer & explanationAnswer & explanation
Correct answer: C. Members can receive care from out-of-network providers without a referral and still receive full benefits.
HMOs are characterized by strict network requirements. Members must generally receive care from in-network providers, and referrals are typically required to see specialists. Out-of-network care, if covered at all, usually comes with significantly reduced benefits or no coverage, making option C incorrect.
Why the other options are wrong
- A. HMO members pay a fixed monthly premium, and services are provided as needed, representing a prepaid system.
- B. HMOs are known for their strong focus on preventative care to manage health and reduce costs.
- D. A PCP acts as a gatekeeper in most HMOs, coordinating all medical care.
Health Maintenance Organization (HMO)
A type of managed care health insurance plan that provides healthcare services through a network of providers, typically requiring a primary care physician (PCP) and referrals for specialists.
- Focus on preventative care.
- Members must select a PCP.
- Limited to in-network providers (except emergencies).
- Services are prepaid via monthly premiums.
Memory trick: HMO: Healthy, Managed, Only-in-network.