Health Insurance: What is a Referral?

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A referral is a special kind of pre-approval that individual health plan members—primarily those with HMOs—must obtain from their chosen primary care physician before seeing a specialist or another doctor within the same network.

Some plans require the referral to be in writing directly from the doctor, while others will accept a phone call from your primary care physician.

In order to make sure that everything is in order regarding seeing a specialist, you should be proactive, and make sure that your insurer has received a referral before you make an appointment with your specialist.

That will you will know that your visit to the specialist will be covered under your health care plan.

Referrals and HMO

Health maintenance organizations, or HMO’s, require an individual to select a primary care physician. The primary care physician is then responsible for managing all of that individual’s health care going forward. The primary care physician becomes responsible for making recommendations as far as courses of treatment, specialist visits, medications, and more. The primary care physician also provides referrals for any other necessary services or specialist visits within the network. These referrals allow you to go see another doctor or a specialist within the health plan’s network.

If you do not have a referral from your primary care physician, or you decide to go to a different doctor outside of your health plan’s network, you will most likely have to pay all or most of the cost for that care, as it will not be covered by the HMO.

An HMO typically only covers visits within the network.

HMOs have become much more common in the individual health insurance market over the last few years as insurers work to control costs. The health insurance exchanges in some states no longer have any PPO options available. 

Referrals and PPO

Referrals are not necessary in a PPO.

A preferred provider organization is a health plan that has contracts with a wide network of "preferred" providers. You are able to choose your care or service out of the network. Unlike a health maintenance organization, in a PPO you do not need to select a primary care physician and you do not need referrals to see other providers in the network.

Because of this flexibility, PPO plans tend to be more expensive than HMO plans with otherwise comparable benefits. And they also tend to attract enrollees with health conditions, since those are the people who will be willing to pay higher premiums in order to access a broader range of health care providers who can be seen without a referral. This is part of the reason individual market insurers have been shifting away from PPOs in recent years.

Payment

Insurance payment for services within a designated network varies between HMOs and PPOs.

In-Network:

HMO and PPO: Regardless of whether you have an HMO or a PPO, for in-network services you'll be responsible for copayments and the deductible, and coinsurance if your plan uses it.

Out-of-Network:

HMO: In an HMO, you are typically not covered for any out-of-network services.

PPO: In a PPO, there is typically coverage for out-of-network care, but the provider is free to balance bill you for the portion that your insurer doesn't cover, since the provider hasn't signed a contract with your insurer. If you choose to go outside of the network for your care, you will usually need to pay the provider initially, and then get reimbursed by the PPO. Most PPO plans have higher annual deductibles and out-of-pocket maximums for out-of-network care, and it's increasingly common to see PPO plans with ​no limit on the out-of-pocket costs you'll incur if you go outside the network.

Updated by Louise Norris.

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