Depending on what type of Medicare Advantage plan you have, you may need a referral from your primary care physician before you can see a specialist covered by your plan.
Common Types of Medicare Advantage Plans
Insurance carriers who have been contracted by Medicare to offer recipients Part C options may offer different types of plans. Understanding how these plans structure their network and cost-sharing obligations can help you make the choice that’s right for you.
Health Maintenance Organization (HMO)
HMOs base their coverage policies around a strictly defined network of health providers and facilities — there may be little to no coverage for services received by providers or at facilities outside of this network. Exceptions to these rules are typically made for emergency reasons or if there are no in-network providers and facilities close enough to the enrollee to treat their needs. When you enroll in an HMO, you usually have to choose a primary care doctor who will give you a referral to see a specialist if need be.
Preferred Provider Organization (PPO)
Like an HMO, PPOs use a chosen network of providers and facilities to control the cost of care to them and their enrollees. However, PPOs allow their members to go outside their network for higher out-of-network costs. You can usually see a specialist without a referral. If you visit a specialist outside of the plan’s network, you will likely pay more.
Private Fee-for-Service (PFFS)
While some PFFS plans may use a network like PPOs and HMOs, it’s not as common. If you choose out-of-network providers, they must still agree to accept coverage terms from your PFFS in order for PFFS benefits to apply to your care. Some may combine prescription drug coverage in their benefits packages. Check with your plan for specific details regarding referrals.
Special Needs Plans (SNPs)
Medicare beneficiaries can enroll in an SNP if they have a qualifying medical condition or circumstance, which helps them access targeted care through a network of providers and facilities that can meet their unique needs directly. Enrollment in an SNP may require proof of the qualifying medical condition and pre-authorization for certain treatments and procedures.
Referrals and Specialists: How Do They Work?
If you need medical attention or diagnostic services that exceed the scope of primary care, your insurance carrier may ask that your primary care physician write a referral to the specialist or team of specialists who will continue your treatment or perform diagnostics. If your plan requires a referral, it’s important to follow the steps outlined by your plan’s policy for acquiring it — otherwise, you may be liable for the full cost of any services provided by that specialist.
Referral requirements are more common in an HMO plan than any other, but that does not mean all HMO plans require referrals to see specialists. HMO carriers may also require referrals only if the specialist is an out-of-network provider. Specialist referrals are also common requirements in an SNP, although certain yearly screenings or treatments that are specific to a recipients qualifying special medical needs may be exempt from this policy. Referrals are not typically necessary for specialists under PPO and PFFS coverage rules.
A referral may also be described as a pre-approval or pre-authorization by your insurer, and Medicare or the carrier of your MA plan may need proof of medical necessity before approving the request for specialist services an treatment. Your primary care physician should be responsible for providing this information, but you may need to make an appointment for a special consultation in order to do that, which may involve cost-sharing obligations for primary care visits.
Does Medicare Cover Urgent Care? (Opens in a new browser tab)
Does Medicaid Require Prior Authorization for Referrals?(Opens in a new browser tab)