Which plan is a managed care system dictating where care is received and covers 100% of costs if in-network?

• A. PPO
• B. Health Maintenance Organization (HMO)
• C. EPO
• D. Medicare

Answer: (B)

This item tests how managed care plans control where you receive care and how costs are covered. An HMO operates with a defined network and a primary care physician who acts as a gatekeeper. You typically must get non-emergency care through that doctor and obtain referrals for specialists, all within the in-network providers. Because care is centralized within the network, in-network services are covered at little to no additional cost, often 100%, after minimal copays. Out-of-network care is generally not covered except in emergencies.

PPO plans let you see whatever providers you choose and pay more if you go out of network, which is why they don’t fit the “100% in-network” and gatekeeper model. EPOs are similar to HMOs in requiring care within a network but may not involve a gatekeeper in the same way. Medicare is a government program with its own distinct structure, not a typical managed care plan dictating network use in the same sense.