- You don’t usually need a referral for specialists if you have original Medicare.
- Even if you don’t need a referral, you have to ensure that the doctor is enrolled in Medicare.
- Some Medicare Advantage plans may require referrals.
Sometimes, to see a specialist, an insurance company might ask you to have a written order — known as a referral — from your primary care provider.
Original Medicare doesn’t usually require a referral, but Medicare Advantage plans might.
Find out what you need to know about referrals under Medicare, and what else to check before making your next doctor’s appointment.
Often insurance companies require you to have a referral, which is a written order from your primary care doctor, before they’ll pay for a specialist’s care.
While Medicare doesn’t require referrals as a general rule, certain situations may require a specific order from your primary care provider.
Original Medicare (parts A and B) doesn’t require referrals for specialist care. However, if you have Part A or Part B coverage through a Medicare Advantage (Part C) plan, you may need a referral before seeing a specialist.
Here are the referral requirements for each section of Medicare:
- Medicare Part A. Part A is the portion of Medicare that covers hospitalization and inpatient costs and treatments. When you have Medicare Part A as part of original Medicare and not through a Medicare Advantage plan, no referrals are required for specialist care.
- Medicare Part B. Part B is the outpatient portion of Medicare. When Part B is part of original Medicare, you aren’t required to get a referral from your primary care doctor in order to see a specialist.
- Medicare Part C (Medicare Advantage). Advantage plans are offered by private insurance companies, and they cover both the inpatient and outpatient costs of Medicare parts A and B, plus other optional services. While these plans are meant to give you more choice in your medical care, they often come with more restrictions as well. Several types of Medicare Advantage plans require referrals for specialist care or certain other services.
- Medicare Part D. Part D is the portion of Medicare that pays for your prescription medications. These plans aren’t mandatory, but they can help offset the cost of your medications. Covered medications are based on tiers and other rules set by the plan and insurance company. Every medication requires a doctor’s order, but referrals aren’t necessary for Part D coverage.
- Medicare supplement (Medigap). Medigap plans were created to help cover out-of-pocket costs you might be left with after your basic Medicare coverage pays its share of your medical expenses. Medigap plans only cover costs for original Medicare, not additional or optional services. Referrals aren’t a part of Medigap.
Medicare Advantage plans are administered by private insurance companies, and the types of plans they offer vary.
Generally, Medicare Advantage plans are split into several types, each with their own rules about referrals. Below is a list of some of the most common types of Medicare Advantage plans and their rules on referrals:
Health Maintenance Organization (HMO) plans
HMO plans are private insurance plans that usually restrict where you can receive medical care to a certain network, with the exception of emergency and urgent care. Some HMO plans may allow you to receive care outside of your network, but these services might cost you more.
These plans also usually require you to choose a primary care doctor in the plan’s network and receive referrals from that doctor for any specialist care. Most HMO plans make a few exceptions for more standard specialty services, like mammograms.
Preferred Provider Organization (PPO) plans
PPO plans are similar to HMO plans in that they’re offered by private insurance companies and provide the best coverage when you stick to doctors and hospitals within the plan’s designated network.
The big difference is that PPO plans don’t require you to choose a particular primary care doctor, and they don’t require referrals for specialist care.
As with HMO plans, you’ll pay less to see specialists within your plan’s network than those that are out of network.
Private Fee-for-Service (PFFS) plans
PFFS plans are private plans that generally offer greater flexibility than some other Medicare Advantage plans. They also have fixed rates, which means the plan will pay only a certain amount for each service.
It’s up to each doctor or provider to accept that rate for their compensation. Not all doctors will accept this rate, though, or they might accept the plan’s rate for some services and not others.
While PFFS plans are more restrictive for providers in terms of the fees they can be paid, they’re generally more relaxed for members. These types of plans usually don’t require you to pick a primary care provider, stick to a particular provider network, or get referrals for specialist care — as long as your doctors agree to accept the fixed rate offered by the plan.
Special Needs Plans (SNPs)
SNPs are a type of private insurance plan offered to people with very specific diseases or medical conditions. Plan coverage is set up to address the needs of members based on their particular health condition.
These plans usually require you to choose a primary care doctor and get referrals for any specialist care.
If you need a referral for a specialist, the first step is to visit your primary care doctor.
A referral for specialty care is sometimes required when you have a disease or health condition that requires specialized, precise care. Conditions that might include referrals to a specialist include:
- neurologic disorders
- heart problems
How to get a referral if you have a Medicare plan that requires one
If you need a referral, you can expect to take the following steps:
- Your primary care doctor will discuss your condition with you and what treatment it might entail.
- Your doctor will suggest you see a specialist to address your needs.
- You’ll be offered suggestions or choices for specialists, with instructions on how to make the appointment. Your provider may also make the appointment for you.
- Your doctor may tell you what to expect from this appointment.
- If you decide to move forward with specialist care, your doctor should provide you with a written plan detailing why you need a referral to a specialist, any tests or special instructions you need before your appointment, how to make the appointment or when it is if it’s been made for you, and any other information you might need to know.
- Similar information will also be sent to the specialist and your insurance plan.
- Make sure you know what information your plan requires to approval a referral, if necessary. Ask your doctor to include any extra information that may be needed.
- Original Medicare doesn’t usually require referrals to see a specialist.
- If you have a Medicare Advantage (Part C) plan, you may need to get a referral from your doctor.
- Always make sure your doctors participate in the Medicare program before making an appointment.