Some private insurance plans require a referral to cover medical specialist care. A referral is an order from your primary care doctor to receive medical treatment from a doctor who specializes in your particular issue, such as a podiatrist to treat diabetic foot ulcers. If your plan requires a referral, your coverage may be limited if you just make an appointment with a specialist office without first receiving a referral from your primary physician.

Original Medicare does not require referrals, but some Medicare Advantage plans do. This article covers the restrictions on care present in Original Medicare, as well as how to deal with referrals under Medicare Advantage.

Does Original Medicare cover specialists?

Original Medicare covers specialists as long as they are enrolled in Medicare. If a doctor is not enrolled in Medicare, your out-of-pocket costs will be higher.

Some healthcare providers accept Medicare but are non-participating, which means they do not agree to accept the Medicare-approved rate in all situations. This may result in you having to pay excess charges. Finally, some healthcare providers fully opt out of the Medicare program. In this case, Medicare won’t cover any amount of the cost.

You can find a Medicare-approved doctor using Medicare’s Care Compare search tool, or ask your current doctor whether they accept Medicare assignment.

Do you need a referral with Medicare Advantage?

Medicare Advantage, also known as Medicare Part C, offers you a way to get your Medicare benefits through a private insurance company. Like other private health insurance plans, there is a lot more variety with Part C than with Original Medicare.

There are four different types of Medicare Advantage plans: HMO, PPO, PFFS, and SNP. Each plan type has different requirements for specialists and referrals, so it’s best to look at the type of plan you are interested in directly.

HMO plans

HMO stands for health maintenance organization. With these plans, you have to get services through the plan’s provider network for your care to be covered. With an HMO plan, you will choose a primary care physician in the plan’s network. This doctor can then provide a referral for you to in-network specialists when the need arises.

PPO plans

PPO plans, or preferred provider organization plans, use a looser form of provider network. Under a PPO plan, you pay less if you visit a provider that is in-network, but can still receive coverage for out-of-network services.

You do not need a referral to see a specialist, but your costs are lower when you see an in-network specialist.

PFFS plans

Medicare PFFS, or private fee-for-service plans, have several unique characteristics. They may or may not have a provider network, and you can still get some coverage outside of the network if there is one. PFFS plans do not require referrals to see specialists, but you have to make sure that a given specialist will accept your plan.

SNP plans

SNPs, or special needs plans, are specifically oriented towards the needs of people with certain diseases or conditions. You usually need to see doctors that are in-network, aside from emergency care or out-of-area dialysis. If you need to see a specialist, you will need a referral.

How to get a referral to see a specialist

If your plan requires a referral for a specialist, you should discuss the options with your primary care physician, who can issue the referral. You can then confirm the coverage options with your insurance plan to ensure that coverage will extend to that specialist. With PPO plans, this will help you understand how much you will pay.

Do you need referrals with Medicare Part D?

Medicare Part D plans provide coverage for prescription drugs. These plans do not require any referrals for specialists, as this type of care does not apply to prescription drugs. All you need is a prescription from your doctor.

Each Part D plan covers a different set of medications at different rates. The full list of covered drugs and their rates is known as the formulary. Check your plan’s formulary to find out how much you can expect to pay.

Does Medigap require referrals?

Medigap plans, also known as Medicare Supplement Insurance, are private insurance plans that help cover your out-of-pocket costs. Due to the nature of these plans, specialists won’t apply in any way, and you don’t need a referral for any part of Medigap.

Because these plans are private, their costs will vary even though each plan's benefits are standardized. Our Ultimate Guide to Medicare Supplement Insurance explains everything you need to know about Medigap.

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