Does Medicare Require A Referral To See A Specialist Under Your Medicare Plan?

Does Medicare Require A Referral To See A Specialist Under Your Medicare Plan?

If you have Medicare coverage and are considering seeing a specialist, you may wonder if you need a referral first. The answer is: it depends.

Lets us break down when your primary care provider must provide a referral to see a specialist with Medicare insurance. Keep reading to learn more!

Does Medicare Require Referrals?

Medicare beneficiaries enrolled in Original Medicare with a Medigap plan don’t require a referral to a specialist. However, you must ensure that the doctor is registered and accepts Medicare which most do.

If you have a Medicare Advantage plan, such as an HMO, you must obtain a referral from your primary care physician to see a specialist. It is essential to check with your health plan to make sure the specialist is a participating provider, as failing to get a required referral may result in higher co-pays or the plan not paying for the services. 

Always call the customer service number of your Medicare Advantage plan to find out if you need a referral and how the procedure works in your medical insurance plan.

Original Medicare Referral Requirement To See A Specialist

Under Original Medicare, a referral from a primary care physician is not required to see a specialist. However, ensuring that the specialist is Medicare-approved and accepts Medicare assignments to avoid high fees charged by the medical doctor. 

For those enrolled in Original Medicare with a secondary insurance plan such as Medigap Plan G, this plan works alongside Original Medicare and will cover all Medicare Assignment fees. However, the Medigap Plan N or lower plan may not cover Medicare assignment fees. 

Most Medicare beneficiaries enroll in Original Medicare with a Medicare Supplement plan to avoid the requirement of referrals and prior authorizations included in Medicare Advantage plans. 

Contact one of our Medigap agents and learn how Medicare works with your Medicare plan. 

Medicare Supplement Referral Requirements To See A Specialist

Medicare supplement plans, also known as Medigap, are private insurance policies that help cover the out-of-pocket costs of Original Medicare, such as deductibles and copayments. Various types of Medigap plans are available, labeled Plan A through N.

Medigap plans A, B, C, D, F, G, K, L, M, and N; referrals are not required to see a specialist as these plans are secondary insurance policies and do not replace Original Medicare. 

Because Original Medicare Part A and B do not require referrals to see a specialist, a Medicare Supplement plan is required to follow the same rules and guidelines.

Medicare Supplement Insurance

Medicare Advantage Plans Referral Requirements To See A Specialist

Medicare Advantage Plans: Health Maintenance Organization (HMO) plans Referral Requirements


A referral is typically required when seeking to see a specialist under a Medicare Advantage Health Maintenance Organization (HMO) plan. While Medicare beneficiaries are enrolled in Medicare Part A and B, when enrolling in a Medicare Advantage plan, enrollees give up their earn benefits under Original Medicare. 

The first step is to schedule an appointment with your primary care physician (PCP). If your PCP determines that you need to see a specialist, they will refer you to an in-network specialist covered by your Medicare Advantage plan. It is important to note that if you see a specialist without a referral from your PCP or if the specialist is outside your medical network, your plan may not cover the services. 

HMO plans focus on care coordination, and healthcare professionals work together to help you maintain your health needs. Therefore, it is essential to obtain a referral from your PCP to ensure that you receive the appropriate care and coverage.

Medicare Advantage Plans: Preferred Provider Organization (PPO) plans Referral Requirements


Medicare Advantage Plans’ Preferred Provider Organization (PPO) plans typically do not need a referral when seeing a specialist. However, ensuring that the specialist you want to see is in-network to reduce your out-of-pocket costs is essential. 

To find an in-network specialist, use your plan’s provider directory or contact your plan’s customer service. If you see an out-of-network specialist, your insurance will cover some of the cost, but you’ll likely have to pay significantly more.

Medicare beneficiaries who enrolled in a Medicare Advantage plan when turning 65 versus a Medigap plan may not qualify for a Medicare Supplement plan, and their only option for improved doctor access is a PPO Medicare Advantage plan.  

Understanding how your Medicare program works and whether your Medicare plan requires you to get referrals is crucial.

Medicare Advantage Plans: Private Fee-for-Service (PFFS) plans Referral Requirements


PFFS plans offer more flexibility than other Medicare Advantage plans, as they do not require referrals to see specialists and may or may not have a provider network. These plans are only available in a small number of areas and are often limited to rural communities.

As many Medicare Advantage plans to require referrals, a PFFS or PPO plan that doesn’t require referrals may be an excellent option for those who do not qualify for a Medigap Plan.

Medicare Advantage Plans: Special Needs Plans (SNPs) Referral Requirements


Special Needs Plans (SNPs) are Medicare Advantage for individuals with specific health conditions. Most SNPs are considered HMO plans which do require referrals to see a specialist. Your primary care doctor can help make an appointment with a specialist covered by your SNP.

No matter the type of Medicare Advantage plan, choosing a primary care doctor and seeing an in-network specialist covered by your medical plan is essential.  

Contact Integrity Now Insurance Brokers to learn the referral rules and what Medicare covers under your plan’s network of doctors.

Medicare Part D

Does Medicare Part D Require Referrals?

Medicare Part D covers prescription drugs ordered by a primary care or specialist doctor and does not require referrals for seeing a specialist. Medicare Part D plans to pass on savings when utilizing a preferred pharmacy vs. other pharmacies in your local area.  

Medicare prescription drug plans are available on a standalone basis or through a Medicare Advantage plan. Medicare beneficiaries enrolled in a Medicare Advantage plan cannot obtain Part D coverage from a standalone plan.

What Happens If You Need A Referral To See A Specialist With A Medicare Advantage Plan?

Medicare Advantage Plans, or Part C plans, are health plans offered by private insurance companies that provide the same level of coverage as Original Medicare but have different rules and restrictions they can apply. Depending on the type of Medicare Advantage Plan, a referral may be required to see a specialist.

Health Maintenance Organization (HMO) and Special Needs Plans typically require a referral from a primary care physician, while Private Fee-For-Service and Preferred Provider Organization plans do not.

To obtain a referral, the member must contact their primary care physician’s office, who will send an electronic referral to the Medicare insurance company. Referrals are typically granted within a few days to a couple of weeks. 

Failure to obtain a required referral before seeing a specialist may result in the insurance plan not covering the visit. 

When Do Primary Care Doctors Provide Referrals To See A Specialist With Medicare?

Primary care doctors are essential in helping Medicare beneficiaries manage their overall health and well-being. One common scenario in which primary care doctors provide referrals to see a specialist is when a beneficiary needs care requiring specialized expertise or equipment unavailable in the primary care setting.

Examples include consultations with a cardiologist for heart disease or an oncologist for cancer treatment.

Generally speaking, Medicare beneficiaries will need a referral from their primary care doctor before seeing a specialist, although this rule has some exceptions. To ensure that beneficiaries receive appropriate care, primary care doctors must understand their patient’s medical needs and work closely with specialists to coordinate care.

Additionally, primary care doctors may refer specialists for more advanced diagnostic testing or other specialized health services, depending on the patient’s health status and individual needs. 

Medicare Advantage

What Are The Requirements For Referrals Under Medicare Advantage Plans?

Under Medicare Advantage Plans, referrals are required for certain medical services. The referral requirements largely depend on an individual’s specific plan.

Generally, referrals are needed for specialist visits and procedures that are considered elective, such as non-emergency surgeries. To obtain a referral for additional Medicare benefits, the doctor an individual sees for a medical concern will typically need to assess and determine if a referral is necessary.

Referrals are usually only covered if obtained within a specified network of healthcare providers, depending on the type of plan a Medicare beneficiary is enrolled in.

Before accessing these additional benefits, Medicare Advantage plan subscribers need to understand the specific referral requirements of their plan to avoid any unexpected costs or issues with obtaining necessary medical services.

It’s also important to note that certain medical services, such as emergency care and your Medicare Part A hospital insurance, may not require a referral. However, Medicare Part B benefits under a Medicare Advantage HMO plan will require you to get a referral to see a specialist. 

Why Seniors Love Medigap Plan G

Seniors prefer Medigap Plan G over other Medicare supplement plans because of its benefits in terms of specialist referrals and provider choice. Here are some reasons why:

  • Medigap Plan G provides the freedom to choose any doctor or Medicare facility in the United States that accepts Medicare without needing referrals or prior authorizations to see a specialist.
  • With Medigap Plan G, seniors don’t have to worry about the hassle of getting a referral from their primary care doctor to see a specialist, which can save time and money.
  • Medigap Plan G covers all the same benefits as other standardized Medigap plans but with the added benefit of not needing referrals or prior authorizations.
  • Seniors who travel frequently or live in different states throughout the year can benefit from Medigap Plan G’s nationwide coverage, as it allows them to see any doctor or Medicare facility that accepts Medicare.
  • Medigap Plan G can help seniors save money in the long run by covering out-of-pocket costs that Original Medicare doesn’t cover, such as deductibles, coinsurance, and copayments.
  • Medigap Plan G covers specialist who accepts assignment and will cover the cost for those who do not.
  • Medigap Plan G does not require non-emergency specialists must be in-network.

Medigap plans can help simplify your life and cover treatment costs from a doctor in or outside of the network. That is because Medigap plans do not have any network restrictions.  


Do Medigap Plans require referrals?


Medigap plans, or Medicare Supplement Insurance, do not require referrals for any medical services covered by Medicare. 

How do I know if I need a referral letter to see a specialist with Medicare?


If enrolled in Original Medicare does not require a referral from your primary care doctor to see a specialist to treat your medical conditions. However, if you have a Medicare Advantage plan, you may need a written referral from your primary care doctor before seeing a specialist from an in-network provider.

The referral rules vary among Medicare Advantage plans, so it is best to confirm the terms of your policy before seeking specialist care. Additionally, some health insurance plans may require a written order submitted to the Medicare insurance provider from a primary care doctor before covering the cost of a specialist visit.

Are there any restrictions on referrals for specialty care with Medicare?


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

Medicare Advantage plans may include different restrictions when obtaining a referral, such as only covering one specialist within your plan.  

What is the cost of seeing a specialist under Medicare?


Original Medicare should cover 80% of the cost of seeing a specialist, but Medicare beneficiaries are responsible for the remaining 20% unless they have purchased Medicare supplemental insurance coverage.

Medicare Advantage plans are not standardized and may charge different rates based on the plan’s summary of benefits. Before seeking health benefits, review your plan with your Medicare Advantage Agent. 

Contact Integrity Now Insurance Brokers 

Integrity Now Insurance Brokers is a Medicare insurance agency specializing in providing high-quality insurance services to seniors needing health care coverage. They have an experienced team of Medicare agents dedicated to helping clients find the best Medicare insurance plans that meet their needs and budget.

Their agents understand the complexities of the Medicare system and offer personalized advice on navigating through it. They provide various products from various providers, so clients can choose a plan that meets their needs.

We aim to help clients make informed decisions about their health care by providing thorough information about insurance plans, rates, and policies. If you need assistance selecting a Medicare plan that meets your needs, Integrity Now Insurance Brokers is an excellent resource that can help you obtain the coverage you need at a price you can afford. 

Contact us today for a Medicare quote.