Key Takeaways

  • Original Medicare typically does not require referrals to see a specialist, offering more freedom in choosing doctors, healthcare professionals, and facilities.
  • Medicare Advantage plans may require referrals, depending on the specific plan type. For example, HMOs and SNPs may restrict specialist choice without a referral from your primary care doctor.
  • If your Medicare plan requires a referral, you and your primary care doctor may discuss your condition and specialist recommendations. They may provide a written plan detailing the need for the referral and any necessary steps before the specialist appointment.

An insurance company might require a written order, often known as a referral, from your primary care doctor before you can see a specialist.

Original Medicare doesn’t usually require a referral, but Medicare Advantage plans might.

Often, insurance companies require you to have a referral before they’ll pay for a specialist’s care.

While Medicare does not generally require referrals, if your primary care doctor recommends visiting a specialist, they may provide you with a referral in case your insurer needs one.

Original Medicare (parts A and B) does not require referrals for specialist care. However, if you have a Medicare Advantage (Part C) plan, you may need a referral before visiting a specialist.

Here are the referral requirements for each section of Medicare:

  • Medicare Part A: Part A covers inpatient hospitalization costs and treatments. If you have Medicare Part A as part of Original Medicare and not through a Medicare Advantage plan, you will not require a referral for specialist care.
  • Medicare Part B: Part B covers outpatient medical services. When Part B is part of Original Medicare, you are not required to get a referral from your primary care doctor to see a specialist.
  • Medicare Advantage (Part C): Private insurers administer Medicare Advantage plans. These plans cover the inpatient and outpatient costs of Medicare Parts A and B, plus additional services. While these plans aim to give you more choices in your medical care, they sometimes come with more restrictions. Several types of Medicare Advantage plans require a specialist referral.
  • Medicare Part D: Part D prescription drug plans cover take-home medications. These plans are not mandatory, but they can help offset the cost of your medications. As with Medicare Advantage, private insurers administer these plans, and drug availability and costs can vary. Medicare plans typically arrange drugs into tiers, and plans may have other rules set by the insurer. Every medication requires a prescription, but specific referrals are not necessary for Part D coverage.
  • Medicare supplement (Medigap): Medigap plans help cover Original Medicare’s out-of-pocket costs, such as deductibles, copayments, and coinsurance. Referrals are not a part of Medigap.

Private insurers administer Medicare Advantage plans, but these plans may vary.

Generally, Medicare Advantage plans are split into several types, each with its own referral rules. Below is a list of some of the most common types of Medicare Advantage plans and their referral rules.

Health Maintenance Organization (HMO) plans

HMO plans usually restrict where you can receive medical care within a specified network, except for emergency and urgent care. Some HMO plans may allow you to receive care outside your network, but these services might cost more.

HMO 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 HMOs in that they provide the best coverage when you visit doctors, other healthcare professionals, and hospitals within the plan’s designated network.

The big difference is that PPO plans do not require you to choose a particular primary care doctor, and they do not require referrals for specialist care.

As with HMO plans, you’ll pay less to see specialists within your plan’s network than those the plan considers out of network.

Private Fee-for-Service (PFFS) plans

PFFS plans 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 payment. 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 healthcare professionals and facilities in terms of the fees they can charge, they’re generally more relaxed for members. These types of plans usually don’t require you to choose a primary care doctor, remain in 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. If not, you may need to pay the difference out of pocket.

Special Needs Plans (SNPs)

Medicare offers SNPs to people with specific medical conditions. Plan coverage addresses the particular needs of members based on their health conditions.

These plans usually involve choosing a primary care doctor and getting referrals for specialist care.

If you need a specialist referral, the first step is to visit your primary care doctor.

You may require a referral for specialty care when you have a health condition that requires specialized, precise care. Conditions that might require specialist referrals include:

  • neurological conditions, where you may visit a neurologist
  • heart conditions, where you may visit a cardiologist
  • different types of cancer, where you may visit an oncologist

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:

  1. Your primary care doctor will discuss your condition with you and explain what the next steps might entail.
  2. They will suggest you visit a specialist to address your needs.
  3. They will offer suggestions or choices of specialists, with instructions on how to make the appointment. Your doctor may also make the appointment for you.
  4. Your doctor may tell you what to expect from this appointment.
  5. 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 your doctor has made it for you
    • any other information that might help you prepare for your visit
  6. Your doctor will also send this information to the specialist and your insurer.
  7. Make sure you know what information your plan requires to approve a referral, if necessary. Ask your doctor to include any extra information they think you may need.

Original Medicare does not usually require specialist referrals. However, you may need a referral from your primary care doctor if you have a Medicare Advantage plan.

Always make sure your doctors participate with or accept Medicare before making an appointment, and contact Medicare or your plan provider if you have any coverage questions.