Managed Care Frequently Asked Questions
Referrals and Physician Networks

Is it legal for my HMO to require me to use certain providers or networks?

Yes. An HMO can limit its reimbursement to a network of providers as long as it complies with certain rules of access:

• The maximum travel distance or time is the lesser of 30 miles or 30 minutes to the nearest primary care, mental health and general hospital provider.
• Specialists must be available within 60 miles or 60 minutes.
• Certain highly specialized care such as organ transplants may be provided by centers of excellence beyond 60 miles.
• Emergency care must be covered even if services were provided by a non-network provider. In addition, the HMO must pay for highly specialized medically necessary care that is not available in network.

When do I need a referral?

Your HMO plan may require you to get a referral from your primary care provider in order to see certain specialty providers. Your evidence of coverage, contract or benefit summary will identify services that require a referral. You can also call your HMO's member services department to verify when a referral is necessary.

What else do I need to know about referrals?

A referral may be given for a specific number of visits or time period. You may need to obtain a new referral if you change primary care providers or your clinic system. If you have a chronic health condition that is monitored by a specialist, you may also seek a standing referral. This type of referral allows for more visits over a longer time period.

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For more information, email health.mcs@state.mn.us.