If I Have Private Insurance Can I See Any Doctor I Want Like a Specialist & It Will Be Covered?

Private health insurance coverage comes in a range of different plan types, each with its own requirements, coverages and allowances. Certain plan types provide more flexibility in cases where a person wants to see a specialist and still have it covered by their insurance. Also, while some plans may cover treatment by a specialist, certain conditions may place limits on coverage amounts.

Private Health Insurance

• People who anticipate needing treatment from a specialist or would like to have the option to visit a specialist should be proactive in choosing among the different plan types available. Some insurers may set up their health plans to operate from within a network of providers and only cover services performed by network providers. Other insurers may grant policyholders the option of going outside a provider network and still cover services performed. The degree of flexibility a plan offers, the types of services covered and the amount of coverage granted for each service all affect how much a policyholder pays for a particular plan. The more flexible plan types allow policyholders to see any specialist they choose, though certain conditions may apply.

In-Network Referrals

• Private health insurance plans that require plan participants to only see providers within a set network typically require participants to get a referral for a specialist from their primary care physician. In turn, the specialist used will most likely work within the same network. Plan types that require in-network referrals for specialists include Health Maintenance Organizations, or HMOs, and Exclusive Provider Organizations, or EPOs. In the case of HMOs, some plans may provide coverage for services received from specialists outside the network, though participants will pay more in terms of out-of-pocket costs. EPO plans provide no coverage for services received outside the network except in the case of medical emergencies.

Out-of-Network Option

• People who wish to see any doctor or specialist of their choosing -- with or without a primary care physician's referral -- may benefit from the options available through Point of Service plan types, or POSs. A Point of Service plan allows participants to see providers both inside and outside an assigned network, though participants pay more in out-of-pocket costs for services received outside the network. If someone wishes to see a specialist who works within the network, a referral from a primary-care physician is required. On the other hand, if a desired specialist works outside the network, a referral from a primary-care physician is not required.

No Referral Options

• The private health insurance plans that have no referral requirements whatsoever offer more in terms of flexibility, which may translate into higher costs for the policyholder in some cases. One plan type, known as Traditional Health Insurance or Fee-for-Service Plans, allow participants to choose any doctor or specialist and require no referral from a primary-care physician. Another plan type, known as a Preferred Provider Organization or PPO, also allows plan participants to see any doctor or specialist of their choosing. However, as with other plans that allow for out-of-network services, participants may have more out-of-pocket costs when using out-of-network providers.