I need to see a specialist and can’t find one that’s in my network. Does this mean it’s not a covered benefit?

Answer: 

It depends on your health plan. Before getting a referral from your doctor for a specialist, remind your doctor of your insurance coverage so they can try and refer an in-network specialist. Receiving care in-network is cheaper than receiving care out-of-network. When care from an out-of-network provider is needed, the coverage you receive is dependent on your health plan.  You need to contact your insurance company to confirm that the doctor's referral is approved by your health plan before receiving care to make sure that they will cover any or all costs.  Your insurance company will let you know whether or not the specialist is in network or out of network for your plan.

If you have a Preferred Provider Organization (PPO) health plan and see an out-of-network specialist, you will get some coverage for the care you received; but, you'll be responsible for paying for more of the costs than if you saw an in-network specialist.

If you have a Health Maintenance Organization (HMO) health plan, you need to get a referral from your primary care provider before you receive care (except in an emergency). If you get a referral for an out-of-network specialist, you will receive coverage until your referral expires (often 90 days). If you still need care from the specialist after the expiration date, you will need another referral from your primary care provider. Additionally, if the specialist recommends you see another specialist, you will need to get a referral from your primary care provider for the new specialist. If you have an HMO plan and don't get a referral for an out-of-network specialist, you will be responsible for all of the health costs.