Finding Care FAQs

With some health plan types, like an HMO or POS, you'll need to choose a PCP. With other plans, like a PPO, you don't need a PCP but it might make getting care easier. This applies no matter what coverage you're eligible for – Individual and Family, Medicare, Medicaid or Group coverage. Learn more about each plan and what you can expect:

• PPO (Preferred Provider Organization): You won't need a PCP with a PPO plan. Finding one might make getting care easier, though. A PCP can help you with preventive and non-emergency appointments, coordinating care and treating chronic illness. Plus, PCP visits often have lower out-of-pocket costs than other appointments, like specialist visits.

• HMO (Health Maintenance Organization): When you enroll in an HMO plan, you'll need to choose a PCP. Your PCP will be your first stop for care. Visit them for your annual checkup and preventive care, when you start to feel sick, for specialist referrals and any non-emergency care. Getting care without going to your PCP first, especially with an out-of-network provider, will cost you more money.

• POS (Point of Service): A POS plan is a mix of an HMO's lower cost with a PPO's flexibility. You'll still need to choose a PCP, especially if you need a specialist referral. Going out of network won't cost you as much as it would with an HMO, though. You should use your PCP for preventive care and annual checkups, specialist referrals and for any non-emergency sickness or injury.

• HDHP (High-Deductible Health Plan): Whether you need a PCP with an HDHP plan depends on how it's structured. Sometimes HDHPs work like PPOs; you won't need to choose a PCP. If they're structured like an HMO, you'll need a PCP and will need to rely on them for standard care and specialist appointments. You should learn how your plan is structured when you sign up.

Read more about:

• Types of Plans
• Get a PCP
• How HMO Works: The Referral Process

Some plans, like HMO, require you to choose a PCP. To change your PCP:

• Log in to your online member account and visit the Find Care page.
• Choose “Change PCP.” 
• If you need to find in-network options, you can search for care under “Find a Doctor or Hospital.” Or, if you already know the PCP you want, search for their name to select them.

Need help? Call the number on your member ID card. Our Customer Service team can answer your questions or walk you through the process

Yes, it does. All Group and Individual and Family plans cover preventive care services. Preventive care is sometimes called routine care. Medicare and Medicaid are also required to cover many preventive care services. You can expect some or all the cost for preventive care to be covered for:

• Annual checkups or physicals for you and your covered dependents
• Standard screenings for things like high blood pressure, high cholesterol or diabetes
• Vaccines for flu, measles, polio, tetanus, HPV and more
• Mammograms, colonoscopies and pap smears, depending on your age
• Pregnancy and pediatric care to cover well-child visits, prenatal care, breast pumps and more

Read more about:

• Visiting Your Doctor With an Individual and Family Plan
• Preventive Care or Medical Care? Know the Difference
• Making Your Health a Priority With Preventive Care

Getting care with an HMO health insurance plan should always start with your PCP. While you have access to a full network of doctors, hospitals and health care professionals when you need care, visiting without a referral from your PCP could cost you more money. With an HMO, it's important to stay in your network for your plan to help cover costs.

To search in-network providers, go to Find Care in your member account:

• Log in to your member account and visit the Find Care page for search results specific to you and your plan. You can also search for providers in the BCBSMT App.
• Visit our website's Find Care page to search as a guest. Keep in mind, you may get results that don't match your plan unless you log in.

Read more about:

• What Is an HMO?
• How HMO Works: The Referral Process

Your PPO plan has a wide network of doctors, hospitals and other health care professionals to offer care. To find in‑network providers, go to Find Care in your member account:

• To search for results specific to you and your plan, log in to your member account and visit the Find Care page. You can also search for providers in the BCBSMT App.
• To search as a guest, visit our website's Find Care page. Searching as a guest is quick, but you may get results that are not specific to your plan.

If you choose a provider who's not in your network, you might end up paying more out of pocket.

Read more about:

• What is a PPO?
• Things to Know About a PPO

You have 2 ways to search:

• Log in to your member account to find in-network  doctors, hospitals, urgent care clinics and more. You can also search for providers in the BCBSMT App.
• Search as a guest on our Find Care page. If you search as a guest, you may get results that aren't specific to you and your plan.

Read more:

• Checking Provider Networks Before You Get Care

If you have an HMO plan, your PCP can help you find an in-network specialist and provide a referral. Usually, they'll help you set up your appointment or connect you with the specialist.

If you have a PPO plan, you probably won't have to get a referral for specialized care. But some specialists ask for referrals, even with a PPO plan, so it might be helpful to meet with your PCP.

What could you need a referral for? Some examples are:

• Specialist appointments: dermatology, cardiologists, neurologists or oncologists
• Chronic care management
• Advanced services: MRIs, CT scans, special lab work
• Behavioral health support: some types of therapy, counseling or psychiatry

Make sure you check your benefits in your online account or ask your provider before moving forward without a referral.

Some tests, services or medicines need approval before you get them. This approval process is called prior authorization, also known as preauthorization. What care might need prior authorization?

• Imaging: CT scans, MRIs, genetic testing
• Surgeries: both inpatient and outpatient
• Medical Equipment: mobility tools like power wheelchairs or prosthetics, oxygen tanks
• Medicines with serious potential side effects or those that can be addictive

When you need prior authorization, we'll work with you and your provider to review the request and make a decision.

To check your prior authorization needs, visit our Prior Authorization webpage.

Read more about:

• BCBSMT's Prior Authorization Process
• Prior Authorization: What You Need to Know
• Do Your Prescription Drugs Need Prior Authorization?
• Utilization Management: Prior Authorization, Recommended Clinical Review and Post-Service Review

BCBSMT won't stop you from seeing any provider you choose, but you'll likely pay more if you don’t use a network provider. Health insurance companies build provider networks to help make sure you have access to top-quality providers who offer discounted rates for our members. Always confirm a provider’s network status before your visit. This includes doctors and hospitals.

When you need emergency care, the No Surprises Act helps cushion you from out-of-network rates and surprise bills. In an emergency, you'll be protected from paying more than your normal in-network share.

Read more about:

• Claims and Coverage FAQs
• Staying In-Network Can Help Cut Costs

Telehealth, is an online option to meet with a licensed doctor, nurse or other provider. You can meet over a call or through video on your cellphone, computer or tablet. It’s one of the fastest growing ways to get care. With telehealth, you can have a virtual visit with a doctor over video chat or phone.

More and more doctors are offering virtual visits for some visits, such as regular check-ins for chronic conditions or medication management. Check with your doctor to find out what options they offer.

Many BCBSMT plans also have access to telehealth companies MDLIVE^® or Teladoc^®. Both of these services help you connect with a provider anytime, anywhere. Some plans even have access to TeleDentistry.

To check your telehealth benefits:

• Log in to your member account and visit the Find Care section.
• There, if you have telehealth benefits, you'll find them as options to click for more information.

Read more about:

• Find Virtual Care
• Keep Health Issues in Check With Telehealth Visits
• Know Your In-Network Health Care Options