Even if you have a primary care physician that you trust, you may need to see a specialist sometime during your life. A specialist is a physician who specializes in a specific area of medicine rather than practicing general medicine.
You may need to visit a specialist if you experience any of the following:
- You are experiencing chronic pain and the treatments you’ve tried aren’t helping.
- You have found other treatments for your condition that your primary care provider isn’t familiar with.
- Your health care providers are giving you contradicting diagnoses.
- Your symptoms are relieved for a short time but reoccur.
- You have received a life-changing diagnosis.
- Your condition requires treatment with advanced technology or a new treatment protocol.
Depending on the type of Medicare coverage you have, you may need to get a letter of referral from your regular physician before you can make any appointments with specialists. Here’s a look at what you need to know.
Does your Medicare coverage require you to get a referral to see a specialist?
If your Medicare insurance coverage is through Original Medicare Part A (hospital insurance) and Part B (medical insurance), you aren’t required to get referrals for visits to specialists. However, to be eligible for Medicare assistance for the visit to the specialist, your provider must accept Medicare assignment and participate in Medicare.
What is Medicare Advantage (Part C)?
Medicare Advantage plans are an alternative to Original Medicare. These Part C plans will include your Part A and Part B benefits, but many plans include additional coverage for little to no extra cost. If you have Medicare coverage through a Medicare Advantage (Part C) plan sold by a private insurance company, you may be required to get a referral from your primary care physician or other health care provider before you can visit a specialist. Your restrictions depend on the type of Medicare Advantage plan you have.
Here’s a look at which of the different Part C plan types require referrals for specialists:
1. Health Maintenance Organization (HMO) Plans
HMOs are geared to keep health care costs as low as possible. For this reason, insurance providers require that plan beneficiaries get their medical care from health care providers who are included in the plan’s network (emergency care and urgent care are not included in these restrictions).
HMOs usually require beneficiaries to choose a primary care doctor from the plan’s network. This is the doctor who is responsible for providing referrals for care with a specialist. You will likely have to visit your primary care physician first for any medical concerns you may have, who will give you a referral to see a specialist.
2. Preferred Provider Organization (PPO) plans
While PPOs are similar to HMOs in that they require enrollees to use a specific network of health care providers, some plans don’t require beneficiaries to select a particular primary care doctor, and they don’t require beneficiaries to get referrals to visit specialists for care. However, you may be required to use specialists that are within the plan’s network.
It’s important to note that in some PPO plans, you may use a specialist that isn’t in the plan’s network for a higher copayment or coinsurance.
3. Private Fee-for-Service (PFFS) plans
PFFS Medicare Advantage plans are Medicare Advantage plans that offer more flexibility than HMOs and PPOs. PFFS plans don’t require you to choose a primary care provider or stay within a set network of providers. You also have the freedom to use any specialist you want, as long as they agree to the plan’s fixed fee rate.
4. Special Needs Plans (SNPs)
Special needs plans offer Medicare insurance to people who have certain illnesses or medical conditions. SNPs typically require beneficiaries to choose and use a primary care physician. They are also required to get referrals for visits to specialists from the primary care physician.
If you were wondering “What is Medicare Advantage and can a Part C plan give me access to the coverage that’s right for me?” compare plans available in your area. You may find a plan that will lower your costs and allow you to see the doctors and specialists you need.