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 the parts of Medicare that a person may need a referral to access and how they can get a referral. It also looks at how referrals work with Medigap.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
A referral is a letter from a primary care doctor to another healthcare professional, asking them to diagnose or treat a patient. The letter provides background information about the individual 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 use the term “referral” for both the letter authorizing the consultation and the actual visit.
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 include:
- Part A, which is hospital insurance.
- Part B, which provides medical insurance.
- Part C, also known as Medicare Advantage, which is alternative insurance 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 enrolled in original Medicare does not need a referral from their primary care doctor to see a specialist. However, a person must check that the specialist is Medicare-approved and currently accepts Medicare assignments.
Private insurance companies administer Medicare Advantage (Part C) plans. Although these often offer additional benefits, they may restrict a person’s choice of healthcare provider, requiring them to use the plan’s in-network providers.
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 providers, unless emergency care is necessary.
A person must select a primary care doctor from within the network, and if they need specialist care, the doctor must write a referral letter. The exception to this rule is for regular specialist services, such as mammograms.
With some HMO plans, a person can use providers outside the network, but this may involve an increased cost.
Preferred Provider Organization (PPO) plans
PPO plans resemble HMO plans in many aspects, with people getting optimal coverage when they use healthcare providers within the network. However, people with a PPO plan do not need to choose a primary care doctor, and they do 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 is not required to choose a primary care doctor, use a specific network of providers, or get a referral letter for specialist care. Individuals can use any doctor or specialist who agrees to accept the plan’s rates.
Special Needs Plans (SNPs)
If an individual has a specific health condition, they may have the option to enroll in an SNP. Insurance companies tailor these plans to the needs of a person with long-term health problems, such as chronic heart failure or diabetes.
A person enrolled in an SNP must choose their primary care doctor, and they will need a referral to access specialist care.
Medicare Part D provides prescription drug coverage through private insurance companies. People can add Part D coverage to their 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 on tiers that dictate the price, with lower levels costing less.
All medications require a doctor or specialist prescription, but an individual 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 opt for this add-on coverage, for which they must pay an additional monthly premium.
As Medigap only involves 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 that they will 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 they can agree to the coverage.
- The specialist then 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 to their plan provider.
It is advisable for people to check that any doctor or specialist they use has Medicare approval and currently accepts Medicare assignments.