Do I Need a Referral to See a Specialist With Medicare?

When Do I Need a Referral to See a Specialist With Medicare?

People with complex medical conditions often seek treatment from doctors specializing in the field. Some health insurance plans require you to have a written order from a primary care doctor before they cover the cost of your visit to a specialist. One of the most commonly asked questions by people considering this level of health care is, “Do I need a referral to see a specialist with Medicare?”

Can You Go to a Specialist Without a Referral?

If you're enrolled in the federal government's Original Medicare program, you don't need a referral to see a specialist. Original Medicare typically allows you to see any doctor you wish, as long as they accept Medicare as payment. 

However, you may need a referral to see a specialist with Medicare Part C plans. If you receive health care coverage through a private insurer, confirm the terms of your policy before seeing a specialist.

Why Referrals Are Required by Some Medicare Insurance Plans

A referral is a written order from a primary care doctor recommending that you obtain the health care services of a specialist. Insurance providers usually ask for a referral before agreeing to pay for services. This helps ensure:

• You're seeing an appropriate specialist for your condition
• The services of the specialist can be of benefit to you

You don’t need a primary care physician to refer you to a specialist if you have Original Medicare, giving you the flexibility to coordinate your own care as you see fit.

Which Medicare Advantage Plans Require Referrals?

You may need a referral to see a specialist with Medicare Part C plans. There are different types of Medicare Advantage plans, each delivering health care services in a unique way.  

The following Medicare Part C plans typically require you to have a primary care doctor refer you to a specialist:

• Health Maintenance Organization
• Special Needs Plans 

The following Medicare Part C plans usually allow you to see a specialist without a referral:

• Private Fee-For-Service
• Preferred Provider Organization

HMOs are generally the only type of Medicare plans that will require a referral.

Which Doctors Are Considered Specialists?

A specialist is a physician with expertise in a specific area of medicine. Specialists usually have several years of advanced clinical training, in addition to general medical training. They may be certified by a governing board in their specialty and are required to keep their skills and knowledge current.

Specialists diagnose, manage and treat certain diseases, conditions, organs or body systems. Here are examples of different specialists:

• Allergist
• Cardiologist
• Dermatologist
• Endocrinologist
• Geriatrician
• Neurologist
• Obstetrician
• Oncologist
• Oral surgeon
• Orthopedist
• Pediatrician
• Podiatrist
• Psychologist
• Rheumatologist
• Urologist
• Vascular surgeon