What are my options to see a specialist outside my HMO provider network?

By Insurance.com Posted : 01/01/2011

Under many HMO plans, you pay the full cost of seeing a provider outside the network unless it's an emergency. This is why you should carefully evaluate the provider network before you sign up with any health insurance plan to make sure it includes a wide enough selection of health care professionals. You also need a referral to see a specialist from your primary-care doctor and obtain prior approval from the HMO for specialty care coverage.

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Some HMOs, though, offer more choices, letting members visit preferred providers outside the network. This lets you have access to both an HMO and a PPO network. You'll pay more out of pocket in the form of coinsurance and deductibles when using the PPO network than you'll pay for seeing a specialist in the HMO network. Still, an HMO plan with a PPO option provides flexibility and more coverage than you'd get from a plan that strictly limits you to an HMO network.

Health insurance plan referral rules

Check your health insurance plan for rules regarding referrals and seeing doctors outside the network, and talk to your primary-care doctor about who you want to see and why. Ask for a referral to the specialist, even if the provider is out of the network. If the HMO doesn't cover the specialty care, you can appeal the decision to the insurance company. Depending on the outcome, you might also consult with your state's insurance department. States regulate insurance and provide information to consumers and help with resolving complaints against insurers.

Recognize that in the end, you might have to pay the full cost of care by a specialist outside the network. Perhaps your primary-care doctor can help you find a suitable specialist within the network instead.

For more, see "Understanding the difference between HMO, PPO and POS."

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