Key insurance terms that start with "R"

An addition to your health insurance policy that adds coverage for specific services or conditions. For example, you might add a rider for dental or vision coverage. Riders typically cost extra but give you expanded coverage for services your base plan doesn't include.

Care to help you recover from injury, surgery, or illness through physical therapy, occupational therapy, or other treatments. Insurance may cover rehabilitation services if they're medically necessary and prescribed by your doctor. You may need prior authorization.

A referral is a recommendation or formal authorization from your primary care physician (PCP) to see a specialist or receive a specific service. Whether you need a referral depends entirely on your plan type.

Referral requirements by plan type:

• HMO: Referrals are typically required to see any specialist. Seeing a specialist without a referral on an HMO plan can result in a claim denial.
• POS: In-network specialist visits usually require a referral from your PCP. Out-of-network visits may not — but you’ll pay more.
• PPO / EPO: No referral required. You can book directly with any in-network specialist.

Even on plans that don’t require referrals, some insurers may require prior authorization for specific specialist services, imaging, or procedures. A referral and prior authorization are not the same thing — referrals come from your doctor, prior auth comes from your insurer.

If you’re on an HMO and your PCP declines to issue a referral for a service you believe is medically necessary, you have the right to appeal that decision.

Surgery to restore the function or appearance of body parts damaged by injury, illness, or birth defect. The ACA requires health plans to cover reconstructive surgery when medically necessary, including surgery following mastectomy for breast cancer. This is different from cosmetic surgery, which insurance usually doesn't cover.