Does my ACA plan cover specialist visits?
Can I see a specialist with my ACA health insurance, and are referrals required?
Yes, ACA-compliant health insurance plans allow you to see specialists, but whether or not you need a referral depends on the type of plan you have. Here’s how seeing a specialist works with different ACA plan types and whether referrals are required:
1. Can I See a Specialist With My ACA Health Insurance?
Yes, all ACA-compliant plans cover visits to specialists. Specialists are doctors who focus on specific areas of medicine, such as:
Cardiologists (heart specialists).
Dermatologists (skin specialists).
Oncologists (cancer specialists).
Orthopedic surgeons (bone and joint specialists).
Psychiatrists (mental health specialists).
ACA plans provide coverage for both in-network and, in some cases, out-of-network specialists, depending on the type of plan.
2. Are Referrals Required to See a Specialist?
Whether you need a referral to see a specialist depends on the type of ACA plan you have. Below are the common plan types and their referral requirements:
A. HMO (Health Maintenance Organization) Plans
Referral Required: HMO plans require a referral from your primary care physician (PCP) before seeing a specialist. Your PCP will manage your overall care and coordinate referrals to specialists as needed.
In-Network Only: HMO plans typically require you to see specialists within the network for coverage. Out-of-network specialists are generally not covered, except in cases of emergency.
B. PPO (Preferred Provider Organization) Plans
No Referral Required: PPO plans generally do not require a referral to see a specialist. You can make an appointment with a specialist directly without needing approval from a PCP.
In-Network and Out-of-Network Options: PPO plans allow you to see both in-network and out-of-network specialists, but you’ll pay less if you use in-network providers.
C. EPO (Exclusive Provider Organization) Plans
No Referral Required: EPO plans typically do not require a referral to see a specialist.
In-Network Only: You must see in-network specialists for coverage under an EPO plan. Out-of-network specialists are generally not covered except in emergencies.
D. POS (Point of Service) Plans
Referral Required: Like HMO plans, POS plans require a referral from your primary care physician (PCP) to see a specialist.
Out-of-Network Care: POS plans may cover out-of-network specialists, but you’ll typically pay more for these visits compared to in-network care.
3. Costs for Seeing a Specialist
The amount you pay to see a specialist depends on your plan’s cost-sharing provisions, including deductibles, copayments, and coinsurance. Here’s a breakdown of potential costs:
Copayments: A fixed amount you pay for each visit. For example, a $50 copayment for a specialist visit.
Coinsurance: After meeting your deductible, you may pay a percentage of the cost (e.g., 20% coinsurance for specialist visits).
Deductible: You may need to meet your annual deductible before your insurance starts covering the cost of specialist visits.
These costs will vary depending on your specific plan and whether the specialist is in-network or out-of-network.
4. In-Network vs. Out-of-Network Specialists
To keep costs lower, it’s best to see a specialist who is in-network. Here’s how to find an in-network specialist:
Insurance provider’s website: Use the directory provided by your insurance company to search for in-network specialists.
Call your insurance provider: You can call your insurance company to confirm which specialists are in-network.
Ask your primary care physician: If you need a referral, your PCP can recommend in-network specialists.
5. What If I See an Out-of-Network Specialist?
If you see an out-of-network specialist, the coverage and costs will depend on your plan:
HMO and EPO plans: Out-of-network specialist visits are generally not covered except in emergencies, meaning you may have to pay the full cost of the visit.
PPO and POS plans: These plans provide coverage for out-of-network specialists, but your out-of-pocket costs will likely be higher than for in-network care.
Key Takeaways:
HMO and POS plans require a referral from your primary care physician to see a specialist.
PPO and EPO plans generally do not require a referral to see a specialist, giving you more flexibility.
For the lowest costs, it’s important to see an in-network specialist whenever possible.
For personalized help finding in-network specialists or understanding your referral requirements, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
