Covered California Certified Enroller Practice Exam

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Do EPO members need a referral to see a specialist who is in-network?

  1. Yes, always

  2. No, they do not need a referral

  3. Only if the specialist requires it

  4. Yes, but only for advanced specialists

The correct answer is: No, they do not need a referral

In Exclusive Provider Organization (EPO) plans, members do not need a referral to see an in-network specialist. This is a defining feature of EPO plans, aiming to provide flexibility and ease of access to specialized care without the need for gatekeeping from a primary care provider. Members can seek treatment from any specialist within the network directly, allowing them to make choices based on their healthcare needs and preferences without the added step of obtaining a referral. This structure contrasts with some other plan types, such as Health Maintenance Organizations (HMOs), where referrals from a primary care physician are typically required. Understanding this fundamental aspect of EPO plans is crucial for assisting clients effectively in navigating their healthcare options.

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