Which health insurance model typically requires a primary care physician referral to see a specialist?

The health insurance model that typically requires a primary care physician (PCP) referral to see a specialist is a health maintenance organization (HMO). In an HMO plan, members are generally required to choose a primary care physician who serves as the gatekeeper for their healthcare. This means that any referrals to specialists must be initiated by the PCP, ensuring that care coordination is maintained and that services provided align with the member’s overall health plan.

This model emphasizes preventive care and often results in lower out-of-pocket costs for members, as the HMO typically negotiates rates with healthcare providers and ensures that they provide care within a network. As a result, members have less flexibility in choosing specialists compared to other models like PPOs, which offer a broader choice of providers and do not require referrals.

In contrast, other options like PPOs allow members to see specialists without needing a referral, indemnity plans provide a greater degree of freedom in accessing different types of care and specialists, and Medicare Advantage varies in referral requirements based on plan specifics but generally may not adhere strictly to the primary care referral model.