How Medicare Advantage plans can help you see specialists without a referral

Many Medicare Advantage (MA) plans require you to visit your primary care physician (PCP) for a referral before seeing a specialist. If you’ve had to see specialists and have been frustrated by the process of getting your visits approved, you may consider switching to a different MA plan that will let you see a specialist without a referral.

Medicare Benefits Solutions

Sep 8, 2021

 5 minutes read
There may be Medicare Advantage plans available in your area, like some HMOs and most PPOs, that won’t require you to get a referral before seeing a specialist. Some plans allow you to visit any specialist within the plan’s network without getting approval from your primary care doctor first, and may even allow you to go out-of-network for a higher copay.
If you aren’t satisfied with your current coverage, take time to explore your options. Compare your current plan to others in your area that will allow you to see specialists without a referral from your primary doctor. If you have questions along the way, or need help narrowing down your choices, a knowledgeable, licensed sales agent may be able to help you find a plan that’s right for you.

The type of MA plan you choose can affect your need for a referral

Many Health Maintenance Organizations (HMOs) and Special Needs Plans (SNPs) require you to get a referral from your primary care physician before seeing a specialist. Some people can benefit from this kind of care coordination or the lower out-of-pocket costs that are associated with an HMO.

Unfortunately, there are downsides to needing a referral before seeing a specialist. You may have to wait days or weeks for an appointment with your primary care physician (PCP) just to get approval to see a specialist. You may be responsible for copays at your PCP’s office as well as your specialist’s office.

If you would prefer to see a specialist without needing a referral from your PCP, you may consider other types of MA plans, such as Preferred Provider Organizations (or PPOs), Private Fee-For-Service (PFFS) plans, or Medical Savings Account (MSA) plans.

These plans may give you the flexibility you need. PPOs are popular plans that allow you to visit specialists without a referral. A PPO may even allow you to see a specialist outside of the plan’s network for a higher copay. After comparing plans to your current coverage, you may find a PPO that gives you the benefits you want at little-to-no additional cost. Or, you may realize that you’re comfortable paying more for a PPO in exchange for greater flexibility in your care.

As you compare plans, consider the overall benefits package and potential out-of-pocket costs. Weigh the costs and benefits based on your personal needs and preferences. Some MA plans offer a wide range of benefits, including prescription drug coverage, vision care, dental care, and fitness programs. Out-of-pocket costs, like coinsurance, premiums, and copays can vary. Some plans will have lower annual out-of-pocket maximum limits.

If you find an MA plan that gives you the freedom to see a specialist without a referral, and still includes the coverage you need at a price you can afford, you may be able to enroll during an enrollment period.

When can you switch plans?

You may be able to switch to a Medicare Advantage plan that doesn’t require you to see your primary care physician for a referral during one of the following enrollment periods:

  • Annual Election Period (AEP). From October 15 through December 7, you have the opportunity to make a change to your Medicare coverage. You can switch from one MA plan to another, drop Original Medicare and enroll in a Medicare Advantage plan, switch PDPs (Prescription Drug Plans), or even drop your MA plan and revert to Original Medicare (and enroll in a PDP at that time).
  • Medicare Advantage Open Enrollment Period (MA-OEP). From January 1 through March 31, you may make one change to your coverage. For instance, you may switch from your current MA plan to another one that will allow you to see a specialist without a referral.
  • Special Enrollment Period (SEP). You may be eligible to make a change to your Medicare plan outside of a regular enrollment period if you experience certain life events, including but not limited to moving out of your plan’s service area, moving into a nursing home, or qualifying for Medicaid.

    Ready to switch to a plan that doesn’t require a referral to see a specialist?

    If you’ve needed to see a specialist with Medicare and have been frustrated by the referral process, consider MA plans that may give you greater flexibility. Compare your current coverage to other plans available in your area. As you explore your options, a knowledgeable, licensed sales agent may be able to help you narrow down your choices and find the plan that meets your needs. And, they may be able to help you enroll when you’re ready. If seeing a specialist without a referral is important to you, find a plan that will meet your needs now and in the future.

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