State RegulationsOH specificDifficulty 2/5
An Akron HIC member schedules an appointment with a dermatologist on her own, without contacting her primary care physician. Under the gatekeeper model, what is the likely consequence for coverage of that specialist visit?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
In the gatekeeper structure of an HIC governed by Ohio Revised Code Chapter 1751, specialty care is accessed through the primary care physician, who evaluates the member and initiates referrals to referral (specialty) physicians. A self-referred specialist visit bypasses that coordination, so coverage generally requires the primary care physician's referral and the unreferral visit may not be a covered benefit under the plan's design.
Why the other options are wrong
- A) The gatekeeper model does not carve any specialty category out of the referral requirement by default.
- C) Premium payment does not guarantee coverage of services obtained outside the plan's coordinated care process.
- D) Retroactive documentation does not cure the absence of the required referral in a gatekeeper design.
Memory hook
In gatekeeper plans, see the PCP first — the referral is the key to specialist coverage.