HMO Guide for Seniors - Office of the Patient Advocate - State of ...

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Questions & Answers
Do I need a referral if I am
seriously ill?
Yes. If you are not in
immediate danger, you
need a referral first. Ask
your doctor for an
“expedited referral.” Your
HMO must reply to your
request in 3 days or less.
I need ongoing care from a
specialist. Do I need to get
a referral for each visit?
Ask your primary care
doctor for a “standing
referral.” It lets you see the
specialist without getting
a new referral each time.
I want to see a specialist
who’s not in my Medicare
HMO’s network. Will the
HMO pay for it?
You must show that there
is no specialist in your
HMO who can give you
the care you need. If your
HMO disagrees with you,
you can file an appeal. See
page 58.
things you can do
Choosing a Specialist
Ask your doctor to give you the name of a specialist.
Or ask your HMO for a list of specialists.
If you need a procedure or operation that is risky,
look for a specialist in your plan who has done
the procedure many times.
To learn about specialists, visit www.abms.org.
Getting a Referral
Ask your doctor how to see a specialist in his
medical group.
Ask how to see a specialist who is in your
Medicare HMO’s network but not in your doctor’s
medical group.
It usually takes about 5 working days to get a
referral.
If your problem is urgent, ask for an expedited
referral. This takes 3 days or less.
If You Have a Problem
Many specialists have long waiting lists. If the
wait is too long, ask your doctor for a referral to
another specialist.
If you can’t get a referral, your doctor should tell
you why. If you disagree, you can file an appeal
with your Medicare HMO. See page 58.
where to find help
American Board of Medical Specialties
Information about specialists’ training
1-866-275-2267 www.abms.org