FAQS: HMO Doctors and Specialists
HMOs are obligated by law to make medically necessary care available to their members within a reasonable time. This means, an HMO must allow you to see another doctor (usually within the plan) if your assigned HMO doctor is not able to see you in a reasonable time frame.
Do I have to see the HMO's doctor?
It depends. HMOs are obligated by law to make medically necessary care available to their members within a reasonable time. So, if the HMO has a qualified doctor in the network, but the doctor is so busy that the member cannot obtain an appointment within a reasonable time, the HMO must provide another doctor, or pay for the member to be seen “out of plan.”
In California, HMOs are also called "health care service plans."
What if my HMO does not have the right doctor or specialist?
Similarly, because of the highly-specialized nature of medical practice today, the HMO may not have the right specialist available within the network. If not, then the member must be referred outside the network to obtain necessary care.