FAQS: HMO Doctors and Specialists

FAQS: HMO Doctors and Specialists

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.”

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.

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.

More HMO FAQs


Los Angeles Insurance Appeals Attorneys

While much of our practice involves work we do for other lawyers, we also handle cases for people and businesses involved in disputes with their insurance companies. If you, your business, or a member of your family is involved in an insurance-related dispute, we might be able to help.

Our analysis of insurance issues is so well respected that we are sometimes consulted by insurance companies themselves. We were recently asked by a major insurer to advise it on whether to make a $17 million claim to its own insurance company.

We do not handle litigation on a high-volume, assembly-line basis, and we are therefore very selective about the cases we take. But when we do take a case, we devote considerable thought, care, and attention to it, so that it moves as quickly through the courts as the judicial system permits.

To find out more about what we can do for you read “Our Litigation Practice for Policyholders.”


For Consumers and Policyholders


Southern California civil appeals attorney, Jeffrey I. Ehrlich, is an appellate specialist certified by the State Bar of California’s Committee on Legal Specialization.