Health insurance can be confusing, especially when you’re simply trying to find a doctor, schedule an appointment, or get the care you need. Terms such as HMO, PPO, in-network, referral, and prior authorization can make the process seem more complicated than it needs to be.
Understanding a few basic rules can make your medical insurance much easier to navigate.
For patients in Dallas and across Texas, the type of health plan you have affects how you choose your primary care provider, whether you need referrals, and what happens if you receive care outside your network.
Your exact coverage will always depend on your individual health insurance plan, but these answers can help you know what to check and what to ask.
Before making an appointment, it’s useful to know three things:
- Is the provider in your insurance network?
- Does your plan require you to choose a primary care provider (PCP)?
- Do you need a referral or prior authorization for the care you need?
HMO vs PPO: What’s the Difference?
An HMO and PPO are two common types of health insurance plans. The main differences involve which providers you can see, whether you can receive coverage outside your network, and whether you need referrals for certain types of care.
Do I Have an HMO or PPO?
Your insurance card and online member account should tell you which type of plan you have. You can also call the member services number on your insurance card.
With an HMO (Health Maintenance Organization), you generally receive covered care from providers within the plan’s network, except in emergencies.
Your plan may also require you to select a primary care physician or provider who helps coordinate your care.
A PPO (Preferred Provider Organization) usually gives you more flexibility. You can typically see specialists without a referral and may receive some coverage for an out-of-network provider – although your costs are usually higher.
An easy way to remember the difference is to think of it like choosing from a restaurant menu. An HMO is closer to a set menu: you choose from a defined selection and follow its rules. A PPO is more like ordering à la carte: you have more choices, but going beyond the preferred options can cost you more.
What Does In-Network Mean?
An in-network doctor or other provider has a contract with your health insurance plan to provide services to its members. Using providers within your network will usually reduce what you pay for covered care.
When checking insurance accepted by primary care doctors, don’t rely only on the name of the insurance company. Insurers offer many different plans and networks.
Check your insurer’s provider directory or call the number on your insurance card to confirm that a particular provider is in network for your specific plan.
What Does Out-of-Network Mean?
An out-of-network provider doesn’t have a contract with your particular health plan. Depending on your coverage, seeing one may mean paying more of the cost yourself or receiving no coverage for that care.
Can I Go Outside My PPO Network?
Usually, yes. PPO plans generally allow you to use out-of-network providers, but you will normally pay more than you would for in-network care.
Before scheduling an out-of-network appointment, check what your plan will cover and what you may have to pay yourself.
How Do I Choose My Primary Care Provider?
How Do I Choose My Primary Care Provider?Start by finding primary care providers who are in your health insurance network. You can then consider practical factors such as location, appointment availability, the services offered, and whether the provider is accepting new patients.
A primary care provider is often your first point of contact for preventive care, common illnesses, ongoing health conditions, and coordinating care with specialists.
Primary care providers can include physicians, nurse practitioners, and physician assistants, depending on state law and your health plan.
Who Can I Choose as My Primary Care Doctor?
If your health insurance requires you to designate a PCP, you’ll generally need to choose an available primary care provider from your plan’s network.
Check your insurer’s online directory, member portal, or app.
You can also call member services and ask whether the provider you want can be designated as your PCP.
How Do I Change My Primary Care Physician?
If you want a different doctor, first check that your new choice is in network and accepting patients.
Under Texas HMO rules, you can change your designated primary care provider up to four times a year.
If your insurance plan requires a designated PCP, you may be able to change your primary care physician through your insurer’s website, app, or member services department.
Some plans don’t require you to formally designate a PCP. If you’re unsure, check with your insurer before your first appointment.
How Do I Set Stella Mattina as My Primary Care Provider?
First, check whether the Stella Mattina provider you want to see is in network for your particular health insurance plan.
If your plan requires you to designate a PCP, log in to your insurer’s member portal or app and look for the option to select or change your primary care provider.
You can also call the member services number on your insurance card.
Your insurer may require you to select an individual provider rather than the clinic itself.
Confirm that your selection has been processed and ask when the change becomes effective before scheduling care that depends on your PCP designation.
Can I Name the Clinic Instead of the Doctor?
It depends on your insurance plan. Some insurers require members to select a specific primary care physician or provider rather than a medical practice or clinic.
If you cannot find the clinic name in your insurer’s directory, search for the individual provider you want to see – or ask your insurer which provider should be selected for that location.
Can an OBGYN Be My Primary Care Doctor?
An OBGYN can provide important preventive and routine health care for women, but that does not necessarily mean your insurance plan will allow you to designate your OBGYN as your primary care provider.
In Texas, women with an HMO can generally see their selected in-network OBGYN for covered obstetrical and gynecological care without first getting a referral from their PCP.
Whether an OBGYN can also be formally designated as your PCP depends on your plan and the provider.
Can I See a Specialist Without a Referral?
It depends on your health insurance plan. PPO members can generally see specialists without a referral, while many HMOs require a referral from a primary care doctor before certain specialist care will be covered.
A referral is essentially a request or order from your primary care provider for you to receive care from a specialist or certain other medical services. If your plan requires health insurance referrals and you see a specialist without getting one, your insurer may not pay for the care.
Don’t confuse a referral with prior authorization. A referral directs you to another provider or service. Prior authorization involves obtaining approval from your insurance plan before certain care is provided.
What Is Prior Authorization?
Prior authorization means your health care provider must obtain approval from your insurance company before providing certain services, treatments, medications, or medical equipment that require approval under your plan.
The insurer reviews the request against its coverage requirements before making a decision. Prior authorization requirements vary between health plans and services.
If your doctor recommends treatment, ask whether your insurance requires prior authorization and whether the doctor’s office will submit the request.
What Is Pre-Op Authorization?
Pre-op authorization generally refers to prior authorization required before a planned surgery or procedure.
Your health care provider may need to submit medical information to your insurer so it can determine whether the planned care meets its coverage requirements.
Authorization doesn’t necessarily mean that you will have nothing to pay.
Your deductible, copay, coinsurance, network status, and other terms of your health insurance plan can still affect your final cost.
Choose Stella Mattina for Primary Care With Your Health Insurance
Understanding your health insurance makes it easier to choose the right providers, avoid unexpected out-of-network costs, and know when you need a referral or authorization before receiving care.
We accept all major insurance plans.
If you’d like to choose a Stella Mattina provider for your primary care in Dallas, check your insurer’s provider directory or contact your health insurance provider to confirm your coverage and PCP requirements.
Then schedule an appointment with Stella Mattina and let us help you stay on top of your health.
Dr. Gonzalo Venegas
Gonzalo Venegas, MD is the Medical Director of Stella Mattina Health and a respected obstetrician-gynecologist with over four decades of service in the Dallas medical community. He has led the Department of Obstetrics and Gynecology at Methodist Dallas Medical Center and contributed to community health through his role on the Parkland Health & Hospital System Board. A dedicated mentor at UT Southwestern, Dr. Venegas is known for his leadership, compassion, and commitment to advancing women’s health and medical education.