Does Medicare Require a Referral to See a Specialist?

Medicare Benefits Solutions
Oct 20, 2020

Your primary care physician can help you with most of your healthcare needs, but you might need a specialist for some of your medical conditions. Knowing when it’s time to visit a specialist and whether or not your Medicare insurance will require you to have a referral in hand can help you get the care you need at a cost you can afford. 

When Should You See a Specialist?

Your primary care doctor will help to establish what your health needs are. They can also help you set and maintain your health goals and set up preventive care. If you have any acute or chronic symptoms, visiting your primary care doctor is usually the first step in getting them addressed. 

This primary care provider can order specific tests to rule out or confirm any medical conditions you have, and they can give you an initial diagnosis. However, they may not have the experience or training required to assist you with any complex health issues you have. When this happens, your primary care provider may decide that you’re better off making an appointment with a specialist. 

In medical practice, there are currently over 120 specialty or subspecialty branches available. Each branch could have a specific focus on a group of diseases, a single disease, an organ system, or a specific organ. Depending on your condition and the complexity of your case, you may visit more than one specialist as they create a tailored treatment plan for you. 

Referral Requirements with Original Medicare Insurance

When you have Original Medicare, Part A hospital insurance and Part B medical insurance don’t require your primary care doctor to write you a referral to visit a specialist. As long as you visit a specialist who accepts assignment, your Original Medicare coverage should apply.

If you have Original Medicare and visit a specialist who does not accept Medicare, you will have to pay out-of-pocket for your care. A few Medigap plans can help pay for the costs associated with a specialist visit, including copays and coinsurance. 

Referral Requirements with Medicare Advantage Plans

Medicare Advantage plans come from private insurers, and they have to give you the same coverage that you’d get under Original Medicare. However, they can also come with additional benefits, and they can have their own provider network. They include: 

• HMO Plans – Health Maintenance Organization Plans focus on care coordination. You have a team of healthcare professionals that cooperate to help maintain your health needs, and you usually need a specialist referral with an in-network provider to get coverage. 
• PPO Plans – Preferred Provider Organization Plans offer insurance benefits for doctors and specialists that are in-network and out-of-network. If you see an in-network specialist, it’ll typically cost less, and you rarely need referrals. 

• PFFS Plans – You typically won’t need a referral with the Private Fee-for-Service Plans, but you want to contact the specialist in question to find out their fee schedule and the coverage they accept. 
• SNPs – Finally, Special Needs Plans most likely won’t need a referral for common exams or yearly screenings by specialists, but many do. Any non-emergency specialist you visit has to be in-network for it to cover. 

Healthcare Specialists Costs

An average doctor’s appointment can cost between $125 and $300. A specialist is more expensive, and it’s not unusual for them to have a cost range of $400 to $900 just for the initial visit. If they accept Medicare assignment, your Medicare insurance should pay for 80% of the cost, and you’ll have to pay the other 20% or have supplemental insurance.