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Medicare Advantage Plan Referrals

Why do some Medicare Advantage Plans require referrals?

If you are enrolled in a Medicare Advantage plan, you may be required to acquire a referral before you can have specialist care covered by your policy. This may not be the case for all Medicare Advantage plan members, so check with your policy provider to determine if your policy requires you to get a referral from a primary care physician before you can seek specialist treatment. This is what you need to know about Medicare Advantage referral requirements.

Do I Need A Referral?

You may not need a referral to seek care from a specialist. According to the Medicare.gov website, members of Preferred Provider Organization (PPO) Advantage plans do not need referrals to see specialists. Similarly, Advantage plans that fall into the Private Fee-for-Service (PFFS) category also do not have a referral requirement for specialist care. 

Unlike those two plan types, Health Maintenance Organization (HMO) plans will likely require you to acquire a referral before you can see a specialist. Although, there are some exceptions. Certain services, such as yearly mammogram screenings performed by a specialist will not require a referral. If you are a member of a Special Needs Plan (SNP), referral requirements will vary. Though, in most cases, you can expect your SNP to require you to acquire a referral before specialist care can be covered. 

Does Original Medicare Require Referrals?

If you are enrolled in Original Medicare and need to see a specialist, you will not need a referral from your primary care physician. But, the specialist you choose to see must be enrolled in and approved by Medicare. 

How To Get A Referral

If you need a referral, the process is easy. Here are the steps:

  1. Discuss your condition with your primary care doctor. 
  2. Ask your doctor to recommend a specialist to address your health needs. 
  3. Accept a list of suggestions and determine whether the doctor wishes to schedule an appointment for you. 
  4. Have your doctor explain what you should expect during the appointment with the specialist. 
  5. Decide whether you wish to move forward with the specialist appointment. 

Find A Medicare Advantage Plan

Whether you wish to enroll in a Medicare Advantage plan that doesn’t require referrals or switch to one that does, the Medicare experts at Trusted Senior Specialists have the information you need to get started. We’ll guide you through the application and enrollment process, allowing you to quickly start receiving the benefits you deserve. Contact us now to schedule a consultation.