Referral

A referral is written or electronic authorization from your primary care provider (PCP) allowing you to see a specialist or receive certain services. Some health insurance plans — especially HMOs — require a referral before they will cover the cost of a specialist visit.

If you see a specialist without a required referral, the plan may refuse to pay, leaving you with the full bill.

Which plans require referrals?

• HMO plans: Almost always require a referral from your PCP to see a specialist.
• POS plans: Usually require a referral for in-network specialists.
• EPO plans: Usually do NOT require referrals, but you must stay in-network.
• PPO plans: Usually do NOT require referrals. You can see any specialist, in or out of network.

Marketplace plans skew toward HMO and EPO to keep premiums lower. PPO plans are less common but offer the most flexibility.

How referrals work

1. You see your primary care provider for an issue beyond their scope (knee injury, recurring migraine, dermatology question).
2. The PCP determines you need a specialist and submits a referral electronically or in writing.
3. The referral specifies the specialist (or specialty), the reason, and how many visits are authorized.
4. You schedule the specialist appointment. The specialist’s office verifies the referral with your plan.
5. The plan pays its share of the specialist visit per your benefits.

Referral vs. prior authorization

These are different:

• Referral: From your PCP to a specialist. Common in HMO plans.
• Prior authorization: From the insurer, approving a specific procedure, drug, or test before it is performed. Required by many plans regardless of HMO/PPO type.

You may need both in some cases — for example, a referral to see a specialist plus prior authorization for the procedure the specialist orders.

Referrals and Open Enrollment plan choice

If you regularly see specialists, this is an important question when choosing a plan:

• Want maximum flexibility, willing to pay more in premium: PPO (no referrals, broader network)
• Comfortable with PCP gatekeeper, want lower premium: HMO with referrals
• Want in-network only without referrals: EPO

A licensed agent can compare plan types in your zip code and explain the tradeoffs.

What if you go to a specialist without a referral?

Depending on the plan:

• HMO without referral: Plan likely will not pay. You owe the full bill.
• EPO without referral: Plan still pays as long as you stay in network.
• PPO without referral: Plan pays at the in-network rate (no penalty).

Always verify whether your plan requires a referral before scheduling specialist visits.

Emergencies do not need referrals

You never need a referral for emergency care. The No Surprises Act (effective 2022) also limits out-of-network surprise billing for emergencies, even at out-of-network ERs.

Related terms

• Network
• Prior Authorization
• Copay

Talk to a licensed agent — they can help you choose between HMO and PPO plans based on how often you see specialists.