If you have Medicare Part C (also referred to as Medicare Advantage), you might be wondering about the referral requirements for seeing a medical specialist who is not your primary care doctor.
Generally speaking, a Medicare Advantage plan requires that you get a referral before making an appointment to see a specialist. This article explains why this policy exists and the different referral requirements for various Medicare Advantage plans.
Primary Care Physicians Versus Specialists
Overall health and address issues related to routine health and preventive care. Further, your primary care physician can often run tests to make an initial diagnosis or rule out some medical conditions.
However, this broad scope of general knowledge may not be a substitute for a condition that requires a more specific area of expertise. This is where healthcare specialists come in. Specialists focus on a particular disease, organ, or system to provide more in-depth and expert care that a primary care physician cannot match. Depending on your condition or complaint, you may be referred to more than one specialist.
Does Medicare Require a Referral for Original Medicare Beneficiaries?
In explaining Medicare to beneficiaries, it helps to distinguish between Original Medicare coverage and the additional benefits that come with a Medicare plan purchased through private insurers.
Original Medicare does not require referrals to see a specialist. As a reminder, Original Medicare insurance consists of Part A and Part B coverage.
Medicare Part A provides hospital insurance, which covers hospital insurance and some home health care services. Medicare Part B works like traditional medical insurance and covers outpatient services and doctors’ visits, as well as durable medical equipment and other medical services.
However, even with Original Medicare, beneficiaries need to take care to ensure that they see a Medicare-approved specialist that will accept Medicare assignment. This means the provider accepts Medicare as full payment for a covered service. To accept Medicare assignment falls under the category of Original Medicare Part A and Part B services.
As a general rule, be sure to ask if the specialist is part of the Medicare program and within your provider network before scheduling an appointment. Otherwise, you could be surprised with a big bill for out-of-pocket expenses.
Medicare Advantage Plans and Referral Requirements
For most Medicare beneficiaries, Original Medicare does not provide enough insurance coverage to provide for all of the health needs we tend to encounter as we get older. As a result, 90% of Medicare beneficiaries opt for some form of supplemental coverage through private insurers and private insurance plans.
While you don’t usually need a referral to see a specialist with Original Medicare, a supplemental insurance plan does require referrals to see a specialist to seek care for medical conditions.
In some instances, Medicare supplement insurance plans such as Medigap will also cover the cost of seeing a specialist. In addition to providing coverage for in-network specialists, Medigap plans could provide additional coverage to cover costs associated with deductibles and copays.
Seeing a Specialist for Your Healthcare Needs with a Medicare Plan
Medicare Part C requires that you get a referral before seeking care from a specialist who is not your primary care physician, though the exact requirements will vary based on the type of medical insurance you have.
Part C Medicare has the following plan options:
- HMO Plans: Short for Health Maintenance Organization, HMO plans involve a team of doctors that focus on care coordination for policyholders. Care coordination involves your primary care provider working with other physicians and in-network specialist providers to maintain your health.
Because your medical care is coordinated by a team of cooperating physicians in Health Maintenance Organization plans, it is imperative that you stay within your own provider network and follow the procedures that require a referral from your primary care doctor.
- PPO Plans: Referred to as Preferred Provider Organization plans, PPO plans usually don’t require a referral to see a specialist for your health needs. However, there are higher costs associated with seeking out-of-network services under a Preferred Provider Organization plan, so it’s typically better to stay in-network to control medical costs.
3. PFFS Plans: Under Private Fee-For-Service plans (PFFS plans for short), you typically don’t need a referral to see a specialist, but you should confirm that they accept your Medicare coverage and understand what the fee schedule is before proceeding with appointments and treatments.
- SNP Plans: Special Needs Plans almost always require a referral to see a specialist. There are rare exceptions for some yearly screenings. As a rule, however, all visits to non-emergency specialists require referrals, and the healthcare professionals must be within the plan’s provider network.
Referrals and Medicare Part D
When people ask, “does Medicare require a referral?” they often wonder about the rules for Medicare Part D insurance, too. Because Part D is for prescription drug coverage, no referrals are required. Instead, your doctor will write you a prescription for your health needs, and your Medicare insurance will cover some or all of the cost.
How Much Do Healthcare Specialists Cost?
The cost to see a specialist can be three to five times the price of seeing your primary care doctor. The additional costs associated with specialists necessitate getting a referral from a primary care provider before proceeding with covered treatment.
The rationale is that your primary care doctor should be doing preventive care and making an initial diagnosis within their medical practice before referring you to a more expensive healthcare provider, even if that provider is within your plan’s network.
By following the referral requirements stipulated by your Medicare insurance company, you can avoid paying additional fees for your healthcare needs, especially if you can manage to stay in-network.
Understanding that Medicare requires a referral for seeing a specialist is important to avoid making costly mistakes. However, different Medicare plans have different rules, so choosing the best Medicare Advantage plans to balance flexibility, the choice of in-network specialists, additional benefits, and overall health insurance costs is vital.
A Medicare advisor can help you decide what plan works best for you.