Generally, you do not need a referral to see a specialist with Medicare. However, the exact answer depends on which type of Medicare plan you have, Original Medicare or Medicare Advantage. Original Medicare prioritizes flexibility and freedom to choose whatever providers and services you need. Certain types of Medicare Advantage plans prioritize cost, which restricts your flexibility. Read on to learn more about which situations require a referral.
What a Referral is Used For
Referrals are required by some insurance policies in order to ensure that a patient is using the proper services for the appropriate symptoms. A referral is a written order by a doctor to see a different medical specialist for evaluation and treatment of a certain medical condition or set of symptoms. In order to get a referral, you would go to your primary care doctor (PCP) and talk about your condition. Your doctor would either suggest that you see a specialist or you would request to see one. Your doctor will then order a referral, often electronically. You will then make an appointment with that specialist and proceed with your care.
While referrals are required by some insurers for the sake of efficiency and reducing medical costs, referrals can decrease a patient’s ability to see which specialists they would like to see when they would like to see them.
Original Medicare vs. Medicare Advantage
Original Medicare – Medicare Parts A and B – does not require patients to get referrals in order to see specialists. Original Medicare is all about flexibility. The patient can go anywhere to any doctor or hospital that accepts Medicare. However, Medicare Advantage is different.
Using a Referral in Medicare Advantage HMO Plans
Medicare Advantage, also called Medicare Part C, is an alternative to Original Medicare. While you still have to purchase Parts A and B, Medicare Advantage offers bonuses like vision, dental, gym memberships, etc. It offers these bonuses in exchange for a monthly premium and less flexibility. There are different types of Medicare Advantage plans. One type, called a Health Maintenance Organization (HMO), is one of the least flexible types of plans. This type of plan does require you to choose a PCP and to get a referral for specialty care. This lack of flexibility translates to savings for the insurance company and savings for the patient. The patient has a lower monthly premium and coinsurance with an HMO plan.
To learn more about your plan’s flexibility and referral requirement, contact us at (662) 844-3300 today.