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Specialist Coverage: HMO vs PPO in California

Need to see a cardiologist, dermatologist, or other specialist? Your plan type determines how easily you can access specialist care and what it will cost. Learn about referrals, networks, and choosing the right plan.

Referral Requirements

Whether you need a referral depends on your plan type:

HMO Plans

Referral Required

  • Must see your PCP first
  • PCP provides referral to specialist
  • Must stay in-network
  • No coverage for out-of-network (except emergencies)
PPO & EPO Plans

No Referral Needed

  • See any specialist directly
  • PPO: Out-of-network covered at higher cost
  • EPO: Must stay in-network
  • More flexibility, often higher premiums

HMO vs PPO for Specialist Access

Feature HMO PPO
Referral needed? Yes, from PCP No
Out-of-network covered? No (except emergencies) Yes, at higher cost
Monthly premiums Generally lower Generally higher
Specialist copays $40-70 typical $50-80 typical
Best for Those who want lower costs and coordinated care Those who want flexibility and direct specialist access
Kaiser HMO: Kaiser operates differently—all your doctors, specialists, and hospitals are part of Kaiser's integrated system, often making coordination easier.

Specialist Visit Costs

What you'll pay for specialist visits depends on your plan tier:

Plan Tier In-Network Specialist Notes
Bronze $60-80 (after deductible) Must meet deductible first
Silver $50-70 May apply before deductible
Gold $35-55 No deductible typically
Platinum $20-40 Lowest cost-sharing

Additional costs to consider:

  • Lab work ordered by the specialist
  • Imaging (X-rays, MRIs)
  • Procedures performed in-office
  • Follow-up visits

Finding In-Network Specialists

Before your appointment, always verify the specialist is in your network:

  1. Check online: Use your carrier's provider directory on their website
  2. Call the carrier: Confirm network status by phone
  3. Ask the office: The specialist's office can verify they accept your plan
  4. Get it in writing: Request written confirmation if unsure
Important: Provider directories can be outdated. Always call ahead to confirm network status before your appointment.

Out-of-Network Specialist Care

What happens if you see an out-of-network specialist?

HMO

Not covered
(except emergencies)

EPO

Not covered
(except emergencies)

PPO

Covered at higher cost
(higher deductible, 40-50% coinsurance)

Need Help Finding the Right Plan?

If specialist access is important to you, our agents can help you find plans with strong networks in your area.

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