Referrals and specialists

By Medicare Benefits - May 4, 2020

A primary care physician can help detect, diagnose and treat a wide range of illnesses and injuries, but if you have symptoms related to a specific field of medicine, or if you’re diagnosed with a specific disease, your doctor may recommend you visit a specialist. Specialists have extensive training and devote their attention to a particular class of injuries or disease. Seeing a specialist can give you access to experts with the knowledge and experience you need to address your particular condition.

Seeing a specialist with Original Medicare

If you have Original Medicare, with or without supplemental Medigap insurance, you can visit any specialist who accepts assignment. This means that the doctor has agreed to accept the Medicare-approved amount as full payment for the services they provide. You don’t need a referral from a primary care doctor before seeing a specialist.

Seeing a specialist with Medicare Advantage

If you enroll in a Medicare Advantage plan, access to specialists will depend on the plan you choose:

HMOs

HMOs (Health Maintenance Organizations) will require you to choose a primary care physician within their network of providers when you enroll. You will have to visit your primary doctor in order to get a referral to a specialist when you need one. You’ll be referred to a specialist within the plan’s network. If you choose to visit a specialist outside of the network, you may be responsible for the full amount of costs incurred.

PPOs

PPOs (Preferred Provider Organizations) do not require you to choose a primary doctor or get a referral to see a specialist. You can visit any specialist as long as they belong to the plan’s network. You may go outside the PPO’s network to see a specialist, but you will likely pay more for their services.

Private Fee-for-Service (PFFS) Plans

You will not need to get a referral to see a specialist if you enroll in a PFFS plan, but it’s important to understand your plan’s terms. Some Private Fee-for-Service plans will allow you to visit any specialist who accepts Medicare, while others will limit you to a specific network of providers. If you go outside the plan’s network, you may have to pay more for your services and supplies.

Special Needs Plans (SNPs)

Special Needs Plans limit membership to Medicare recipients with specific conditions or circumstances. You will usually have to choose a primary care physician or care coordinator, and you will likely need a referral to see a specialist. Special Needs Plans give you access within the plan’s network to experts in the field that affects their members. If you qualify for a Special Needs Plan, compare plans and understand the process for referrals and specialists before enrolling.

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