Managed care plans like HMOs and PPOs offer plan members low insurance rates and, as they control costs by limiting medical bills, they can be a great resource for consumers. However, it's sometimes difficult to know what is and isn't covered under a managed care plan. Specialist referrals can be particularly tricky, as many managed care plans are limited. Doctors who specialize in certain fields might not be a part of the plan, and when a specialist's services are necessary, patients might feel that their options are limited.

It's true that specialist referrals need to be carefully controlled, as managed care plans are able to offer lower-than-average rates to their policy holders by restricting medical bills. For instance, an HMO will often prevent its members from visiting a specialist unless a policy holder's primary physician has declared that the services of the specialist are essential to the patient's care. If a policy holder makes an appointment with a health care specialist without following the official procedure of the HMO, the corresponding health insurance claim may be denied. As such, policy holders should contact their insurance agents or ensure that their primary caregivers have filed the necessary paperwork before visiting any out-of-network specialist. This process can usually be completed very quickly but, even so, it's best to move as quickly as possible to ensure coverage for the out-of-network physician.

Some other types of managed care plans may give policy holders a bit more freedom. A Preferred Provider Organization (PPO) will usually cover specialist referrals, but when a specialist is outside of the PPO's network, the policy holder will have to pay an elevated rate for services. Coinsurance rates or co-payments may be significantly higher and this can make some types of specialist visits extremely expensive, especially if the specialist is being consulted about an elective surgery. However, if the patient's primary physician determines that a specialist is necessary for the patient's health care, the PPO might still cover the associated medical bills as if the specialist was within the network. Again, policy holders should check with their insurance agents to find out what is and isn't covered.

When the services of a medical specialist are absolutely essential, most health insurance plans will have a way to pay for those services. It's always best to read through health insurance quotes in their entirety before buying a plan to ensure that coverage will be adequate for out-of-network physicians and hospitals. Policy holders should also check with their state insurance commissioners, as many states have laws that prevent insurance companies from denying relevant claims except under extremely specific circumstances.