Are Specialists Covered by Private Health Insurance?

Navigating the world of health insurance can be complicated, to say the least. From determining reasonable costs to figuring out what exactly you can get coverage on, there are a lot of different factors to consider. But one common question people have when exploring insurance options, or looking into their current insurance plan, is whether or not specialists are covered by private health insurance. So let’s take a look at this question and provide some helpful information.

How does health insurance work?

First off, it’s important to understand how health insurance actually works. Health insurance works mostly the same whether you have private or public insurance—you’ll always have to pay a monthly fee for your insurance plan to stay active, whether you actually sought medical services or not. Along with your monthly premium, you’ll have to pay when you do seek medical services until you reach a certain amount determined by your insurance; this is called a deductible. After you have paid a certain amount, the remainder of your medical expenses will be covered by your insurance.

Another option for health insurance is short term health insurance. Short term health insurance plans provide coverage for only a certain period of time—these plans are often much cheaper and can be beneficial in numerous ways. Students and travelers can benefit from short term plans because they can ensure they have insurance only for the time they need it. Additionally, there aren’t any enrollment restrictions, so this insurance can be applied for at any time.

But no matter the insurance plan, it’s important for people to have some sort of health insurance coverage. This will help lessen the financial burden in the event of an injury or illness.

Which types of plans cover specialist appointments?

Sometimes, people need to see a specialist. For example, someone with poor hearing may need to see an audiologist—many people visit audiology offices for a variety of reasons. Some people may find their hearing just isn’t as good as it used to be or there may be an even bigger problem, like ear pain or sudden and complete hearing loss. Audiologists can help diagnose hearing problems, like tinnitus. In the event that a specialist is needed, it’s important to get an appointment sooner rather than later. But many people may put off seeing a specialist because they don’t know whether the appointment will be covered by insurance or not.

Fortunately, there are many insurance plans that do cover specialist appointments. In fact, because private insurance plans partner with several healthcare providers, most plans cover specialist appointments to some level. A few of the most common types of private health insurance plans include Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans, Point of Service (POS) plans, and Exclusive Provider Organization (EPO) plans.

HMO plans do cover specialist appointments as long as patients receive a referral from their primary care physician—but their PCP has to b within the predetermined network of physicians. Under a PPO plan, patients don’t always have to have a primary care physician and can see a specialist without a referral. POS plans do require a referral to see a specialist and EPO plans do not require a referral. Ultimately, it depends on the type of plan a person has and whether or not they’re allowed to seek services from out-of-network physicians without a referral. But generally, specialists are covered by all insurance plans, some just require a referral.

Determining What Your Plan Covers 

Before you sign up for an insurance plan, you should be given a list of services that the plan does and does not cover. But if you already have insurance and aren’t sure whether or not a specialist will be covered, there are a few different things you can do. You can find your insurance binder, whether it’s a physical stack of papers or an online portfolio, and look to find information on what is and isn’t covered in your policy. You can also call your insurance company for quick and easy answers—you may also be able to ask the specialists’ office if they can tell you whether or not your insurance will cover the appointment.

Seeking the help of a specialist is something that shouldn’t be postponed. So if you require the services of a specialist, talk to your insurance company and make an appointment sooner rather than later.

Written By
Charles Moreno
Budget Analyst | Contributing Writer
Charles Moreno

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