Both Vermont-licensed carriers which offer HMO plans in the state, Blue Cross Blue Shield of Vermont (BCBS of VT) and MVP Health Care, no longer require patients to obtain referrals from their Primary Care Physicians (PCP’s) for these services to be covered before seeing a specialist physician. The specialist provider must still be a member of the carrier's medical network. An exception would be certain Medicare and Medicaid HMO plans that still require PCP referrals.

This new policy eliminates the major objection to Health Maintenance Organization (HMO) plans voiced by many Vermonters. New members must still designate their PCP at the time of enrollment, but they are free to see their specialist physician(s) for health care expertise that is beyond the scope of their primary doctor.

These HMO plans, offered by both BCBS of VT and MVP, do require notification (referred to “pre-admission certification”) in advance of non-emergency hospital admissions, out-patient hospital treatment or surgery or the more expensive diagnostic services such as an MRI. The subscriber or a family member is also required to contact the insurance carrier within 48 hours of an emergency room visit.

Contact Benefit Design & Strategies to help you find the right HMO plan for you and your Vermont employees.

It should be noted that some very specialized practices will only accept referral appointments made by another physician to avoid unnecessary or inappropriate office visits. Likewise, some carriers will limit the number of visits to certain specialties, such as mental health and chiropractic, or require pre-approval for more than the initial treatment.