HMO Members: Learn About Your Out-of-Network Health Care Options

This article is intended for HMO members enrolled in an employer health insurance plan.

BlueLincs HMO^SM members are required to get prior authorization or precertification for services that are not done by your primary care physician (PCP).

You’ll need to check with your PCP for this referral or confirm whether a referral is needed. Your benefits may not be available without it.

With a BlueLincs HMO-based plan, you can choose from a large provider network. The BlueLincs HMO network includes a range of independently contracted hospitals, doctors and other health care providers.

When you enroll in a BlueLincs HMO plan, you'll need to pick a provider to be your PCP. If you don't have one, we will assign one for you. You can change it later if you want a different PCP.

Your PCP’s office is the best place to start when you need care. Your PCP:

• Is familiar with your health care needs and medical history
• Provides basic medical care
• Prescribes medication
• Refers you to a specialist when needed

All non-emergency specialty care must be approved in advance by your PCP. Your PCP will provide a referral for specialist visits, tests and other services. And any follow-up care must be coordinated by your PCP.

You don’t need a referral for mammograms or OB/GYN and behavioral health services if the providers are in your HMO network.

If you decide to see a specialist or another health care provider for non-emergency care without getting prior authorization, you may be responsible for all charges.

If you need emergency care, get care from the nearest emergency or urgent care facility and call your PCP within 48 hours. All follow-up care required after an emergency should be coordinated by your PCP.

No Surprises Act

Providers who are in your plan’s network have negotiated with your health plan on how much to charge for certain services. An out-of-network provider has not signed a contract with your health plan, so they may charge a different amount.

If an out-of-network health care provider bills more than the approved charge for covered services, they may bill you for the difference. That is called balance billing. 

Balance billing, or surprise billing, happens when you get an unexpected bill, like if you go to an in-network hospital or facility, but one of the doctors or specialists is not in your plan's network.

The No Surprises Act offers protection in some cases from balance billing and surprise billing.

• Emergency Services: The law protects members from balance billing in some emergency service situations.
• Professional Services: The law protects members from balance billing in some situations where the hospital or facility might be in-network, but the provider isn’t.
• Air Ambulance Services: The law protects members from balance billing in some situations when air ambulance transport was required and was received from an out-of-network provider.

Learn more about how this federal law affects your health insurance plan.

Always Check

Please keep in mind that a provider’s network status may change. Make sure all of your providers are in your network. You can use Provider Finder^® to search for doctors, hospitals, pharmacies, urgent care facilities and more.

Originally published 11/18/2019; Revised 2022, 2023, 2024