Do I Need a Referral to See a Specialist With Medicare?

It’s common for many health insurance plans to require a referral from a primary care provider in order to see a specialist. So, do you need a referral to see a specialist with Medicare? 

This answer varies based on whether you have Original Medicare or a Medicare Advantage plan. Read on to learn more about Medicare and referrals. 

Original Medicare & Referrals

Original Medicare (Medicare Parts A and B) does not require referrals to see specialists. Medicare beneficiaries can select any doctor, as long as they accept Medicare as payment. This means you are free to visit any primary care doctor, specialist or hospital that accepts Medicare assignment. However, depending on if you carry a Medicare Supplemental plan and which plan you carry you may still be responsible for any required copayment or coinsurance.  

Medicare Advantage & Referrals

Medicare Advantage plans, or Medicare Part C, are private insurance alternatives to Original Medicare. However, unlike Original Medicare, these plans work similarly to employer-provided group health insurance in that you can’t just visit any provider who accepts Medicare assignment. This also means that referrals are often necessary to see a specialist. We’ll take a closer look at each type of Medicare Advantage plan below. 

• HMO Plans. In most cases, you do need a referral to see a specialist. However, yearly screenings, such as mammograms, do not require a referral. 
• PPO Plans. In most cases, you do not need a referral to see a specialist. However, your costs for covered services will usually be lower if you use a plan specialist rather than a non-plan specialist.
• PFFS Plans. You do not need a referral to see a specialist. 
• SNPs. In most cases, you do need a referral to see a specialist. However, similarly to HMO plans, services like yearly mammograms and in-network pelvic exams do not require referrals. 

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For more information on Medicare coverage, contact Crumes Insurance today. We’ll help you find the best plan to fit your unique needs!