Today in the United States, Medicaid covers over 17 percent of all U.S. healthcare spending and assists with healthcare expenses for more than 75 million Americans of all ages. Where Medicare is a health insurance program, Medicaid is an assistance program that helps low income individuals and families with their medical needs and expenses.
Every U.S. state runs its own Medicaid program, but they are all based on federal guidelines. Each state has its own regulations regarding what services are covered, when written referrals are necessary, and which referrals require prior authorization.
Through Medicaid services, a referral is issued in writing by your primary care physician when he or she feels it is necessary for you to visit another health care provider for treatment or tests. A prior authorization for this referral is necessary in some cases. The authorization is issued by your Medicaid provider who reviews the case and allows you to visit the specialist or other health care provider.
Because states may vary in their requirements for coverage of services, referral allowances, and need for prior authorization, you should contact your local Medicaid office for details. Your health care provider can give you information also.
Do You Need a Written Referral for Medicaid Services?
In most cases, if your primary health care provider feels you need to see a specialist or another physician, he or she provides you with a written referral order. Every state has different requirements, but a general list of situations where you may need a referral can include the following:
• Diagnostic exams such as x-rays and lab tests
• Outpatient hospital services that are scheduled (not emergencies)
• Scheduled inpatient admission to a hospital
• Clinic services
• Kidney dialysis
• Visits to providers who are outside the network of your Medicaid provider
• Durable medical equipment (DME) rental
• Home health care services.
When is Prior Authorization Required?
In some referral cases, you may first be required to obtain prior authorization from your Medicaid provider. The reason for getting prior authorization is to establish whether the service is a medical necessity, or if it is for clinical appropriateness (if it will be helpful to you, the patient). Although the list varies in each state, the following instances usually require prior authorization:
• Non-formulary medications
• Major surgery
• General anesthesia
• Rehabilitative services
• Nursing home care
• Skilled nursing care
• Hospice care
• Specialized care
For situations when prior authorization is required, your primary care provider contacts your Medicaid provider either by phone or in writing. Then, Medicaid makes a decision and reports back to your primary care provider who then makes the referral. In most cases, the authorization takes up to 14 days unless it is an emergency.
In some cases, the authorization may cover a specific period, or a specified number of visits to the specialist. But, if another health care provider becomes involved in the same case during this period, another referral and authorization is necessary. Your primary care provider knows which cases require prior authorization.
If you need emergency room services or post stabilization services, these do not require prior authorization.
When Does Medicaid NOT Require a Referral?
Depending on the state you live in, Medicaid does not generally require referrals or authorizations for the following situations:
• Visits to your primary care provider
• Emergency care
• Routine or preventive services from an OB/GYN in your network
• Family planning services
• Care for sexually transmitted diseases (STDs)
• Vision care with a physician in your network
• Dental care for children when the dentist is in your network
• Emergency mental health care
• Services for alcohol or drug related problems
• Up to ten mental health care sessions
Do Dual-eligibles Need Referrals and Prior Authorizations?
For people who are dual-eligibles and have coverage through Medicare together with Medicaid services, when using coverage through Original Medicare, procedures that are medically necessary do not require referrals or prior authorization.
For more information regarding referral and authorization requirements in your area, you can ask your primary care provider or talk to an agent at your local Medicaid office.