How Do Referrals Work in My HMO Plan?
When you have an HMO plan, a primary care physician, or PCP, is your first point of contact for care. If your PCP can’t provide the care you need, he or she will give you the name of a doctor who can. That’s called getting a referral.
In some cases, HMO plans won’t help pay for care you get from doctors without a referral. You can avoid unexpected bills by understanding how referrals work.
Here’s an example of how referrals work. You’ve had a runny nose, congestion and itchy eyes for a few weeks. Is it a cold? Is it allergies?
When you have an HMO plan, you go to your PCP first to find out. After an exam, she rules out a cold and suspects it may be an allergy. She refers you to an allergist. The referral may be electronic, on paper or called in.
Getting a referral doesn’t guarantee your plan will cover or help pay for everything. For example, you may have a copay, need to meet your deductible, or pay for things your plan doesn’t cover.
But without a referral, you could pay more or all of the costs.
Referrals need to come from your current PCP if you want your plan to cover or help pay for your care when:
Some other things you should know about referrals:
Your plan helps pay for these services without a referral: