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If I switch to an HMO, do I need a referral to continue seeing the same specialist?
My employer offers both an HMO and a PPO option. I've been on the PPO for a few years, but I want to switch to the HMO to cut down on the out-of-pocket expenses. I understand that I would then need to choose an in-network primary care physician, and I have no problem with that since I'm not really that picky when it comes to general care doctors.
The problem is that I have a chronic condition requiring treatment with a specialist, and I am a little more picky about that. I've been going to one specialist in particular for a while, and I want to continue going to her. But for insurance to cover those treatments, I would need my official primary care physician to refer me to her, right? Does that mean I would have to stop going to the specialist until I get that referral? Can you usually request that a primary care physician refer you to a particular specialist? And does the referral process take long?
(I tried calling my insurance company to ask this, but I was on hold for so long that I eventually had to hang up.)
6 Answers
- AnonymousLv 71 decade agoFavorite Answer
You would need the referral, AND, they would need to be covered under the HMO plan. Just because they are on the PPO, doesn't mean they'll be on the HMO.
You'll have to spend the hold time, to find out for sure. Sorry.
- 1 decade ago
You would need the referral UNLESS it's an open-access plan which doesn't require referrals. Call the broker and call the doctor that you'd choose to see what the process is. Depending on the condition they may not refer you to a specialist. The idea of an HMO is that 85% of what ails you can be fixed at your PCP...which is cheaper than a specialist.
- Anonymous1 decade ago
Yes, you would need a PCP referral. And that specialist would have to be "in network" for the HMO plan.
- ZarnevLv 71 decade ago
Yes, you would need to wait to get a referral from your new primary care doctor. Be aware that sometimes a primary doctor will have select specialists that they will refer you to so it is possible that your new doctor would not refer you to the specialist that you want to see.
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- Anonymous5 years ago
Not really a question, but yes I'm on board with the times so I do know about HMO's. Thanks for helping enlighten others, even if it is just on Yahoo Answers.
- Anonymous1 decade ago
maybe not. there are some hmo's that have something called open access. as long as the provider is in network, no referrals are needed. i suggest you contact your benefit rep for specifics of your plan.
Source(s): benefit rep
