A primary care doctor can help people with most healthcare needs. However, an insurance company may ask for a written referral from a doctor when a person needs specialist care.
This article discusses Medicare referrals, including which parts of Medicare may require a referral to access specialist care and how a person can get a referral. It also looks at how referrals work with Medigap.
Medicare resources
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A referral is a letter from a primary care doctor to another healthcare professional, asking them to provide a diagnosis or treatment to a specific person.
The letter provides background information about the person to help the specialist or other healthcare professional understand the situation and decide how best to help the person.
When a doctor writes a referral letter, they must indicate the consultation or diagnostic test that is medically necessary.
People may use the term “referral” to describe both the letter authorizing the consultation and the actual visit.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Federally funded Medicare provides hospital and medical insurance for older people in the United States and some younger people with certain disabilities or health conditions.
The program’s four parts are:
- Part A, which is hospital insurance
- Part B, which provides medical insurance
- Part C, also known as Medicare Advantage, which is an alternative to Original Medicare (Part A and Part B)
- Part D, which offers coverage for prescription drugs
The various Medicare parts have separate rules about the need for a referral letter.
Medicare Part A and Part B
A person who is enrolled in Original Medicare does not need a referral from a primary care doctor to see a specialist.
However, a person must check that the specialist is Medicare-approved and currently accepts Medicare assignments.
Medicare Advantage
Private insurance companies administer Medicare Advantage (Part C) plans. Although these plans often offer additional benefits, they may restrict a person’s choice of healthcare professional, requiring them to use the plan’s in-network professionals.
There are several types of Advantage plans, and the rules about referral letters may differ among them.
Health Maintenance Organization (HMO) plans
Most HMOs require a person to use the plan’s network of healthcare professionals, except in the case of emergency care.
A person must choose a primary care doctor from within the network, and if the person needs specialist care, the doctor must write a referral letter. This rule has an exception for regular specialist services, such as mammograms.
With some HMO plans, a person can use healthcare professionals outside the network, but this may involve an increased cost.
Preferred Provider Organization (PPO) plans
PPO plans resemble HMOs in many ways, with people getting optimal coverage when they use healthcare professionals within the network.
However, a PPO plan does not require a person to choose a primary care doctor, and it does not require a doctor’s referral letter for specialist care.
Private Fee-for-Service (PFFS) plans
PFFS plans are among the most flexible Advantage plans. They use a fixed rate system, and the plan pays a certain amount toward each health service.
A person enrolled in a PFFS plan does not need to choose a primary care doctor, use a specific network of healthcare professionals, or get a referral letter for specialist care. People can use any doctor or specialist who agrees to accept the plan’s rates.
Special Needs Plans (SNPs)
If a person has a specific health condition, they may have the option to enroll in an SNP. Insurance companies tailor these plans to the needs of people with long-term health conditions such as chronic heart failure and diabetes.
A person enrolled in an SNP must choose a primary care doctor and will need a referral to access specialist care.
Learn more about Medicare Advantage plans.
Part D
Medicare Part D provides prescription drug coverage through private insurance companies. People can add Part D coverage to Original Medicare. Medicare Advantage plans generally include prescription drug coverage among their benefits.
Each Part D plan has a list of covered drugs, which is called a formulary. Different medications appear in tiers that dictate their prices, with drugs in lower tiers costing less.
All medications require a prescription from a doctor or specialist, but a person does not need a prescription drug referral.
Private insurance companies offer Medigap plans to help people pay for out-of-pocket costs that Medicare does not cover. People with Original Medicare can choose to add this coverage and must pay an additional monthly premium for it.
Because Medigap involves only out-of-pocket expenses, it does not require referrals.
For those enrolled in a Medicare plan that requires a referral for specialist care, there are some basic steps leading to the issuance of the referral letter:
- A person’s doctor recommends a consultation with a specialist.
- The doctor provides a written referral, which includes the reasons for the referral. A person will also receive information about any diagnostic tests they need to undergo before the appointment and any other specific instructions. The doctor sends the same information to the specialist and the person’s insurance company.
- The person’s insurance company may request additional information before it will agree to the coverage.
- The specialist confirms the appointment.
People with Original Medicare do not need a referral to see a specialist. However, people with certain Medicare Advantage plans may need a written referral document. The rules on this vary among plans, so anyone who needs more information should speak with their plan provider.
It is advisable for people to check that any healthcare professional they use has Medicare approval and currently accepts Medicare assignments.