[Health Insurance] 14, Health Maintenance Organizations HMOs

This podcast is made by Ran Chen, who holds an EA license, Insurance and Securities licenses (Series 6, 63, 65), and the CFP® designation. He is passionate about opening access to high-quality exam preparation resources and helping learners prepare more effectively for professional certification exams. In this episode you will learn: - The two defining characteristics of an HMO are its prepaid service model and the use of a Primary Care Physician (PCP) as a gatekeeper. - HMO members must use in-network providers, and there is no coverage for out-of-network care except in cases of a true medical emergency. - A referral from the PCP is mandatory to see a specialist; self-referrals will result in a denied claim. - The main types of HMO models (Staff, Group, IPA) are differentiated by the employment or contractual relationship between the HMO and its physicians. - A key distinction from a PPO is that an HMO requires a gatekeeper and generally does not provide out-of-network benefits, whereas a PPO does. For more free exam prep tools, practice questions, and AI-powered explanations, visit https://open-exam-prep.com/ or YouTube Channel: https://www.youtube.com/@Open-exam-prep