Commission for Case Manager Certification (CCMC) Exam 2025 – 400 Free Practice Questions to Pass the Exam

The Health Maintenance Organization (HMO) model is characterized by a strong emphasis on coordinated care managed through a primary care physician (PCP). In this model, members are usually required to select a PCP, who serves as the main point of contact for all their healthcare needs. When a patient needs to see a specialist, they must first obtain a referral from their PCP. This process is designed to ensure that care is well-coordinated, which can help manage costs and maintain quality.

The HMO model contrasts with other models where referrals are not typically necessary. For instance, in a fee-for-service model, patients can see any provider without needing a referral, which allows for greater flexibility but can lead to higher costs. Similarly, Preferred Provider Organizations (PPOs) also allow patients to visit specialists without referrals, although out-of-network visits may incur higher costs. Capitation, on the other hand, refers to a payment model rather than a referral process, focusing on a per-member per-month payment that incentivizes efficient care delivery without direct referral requirements.

Therefore, the unique structure of HMOs necessitates referrals from the primary care physician for specialist services, which is a distinctive aspect of this type of insurance model.