Does Medicare require referrals? (2023)

  • You usually don't need a referral to a specialist if you have Original Medicare.
  • Even if you don't need a referral, you still need to make sure the doctor is enrolled in Medicare.
  • Some Medicare Advantage plans may require referrals.

To see a specialist, an insurance company may require a written order, known as a referral, from your primary care physician.

Original Medicare usually doesn't require a referral, but Medicare Advantage plans do.

Find out what you need to know about Medicare referrals and what to check before your next doctor's appointment.

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Insurance companies often ask you for a transfer, that is, a written order from youfamily doctorbefore paying for specialized treatment.

(Video) Does Medicare Require a Referral? |

While Medicare generally does not require referrals, certain situations may require special orders from your primary care physician.

Original Medicare (Parts A and B) does not require referrals for specialist treatment. However, if you have Part A or Part B coverage under a Medicare Advantage plan (Part C), you may need a referral before you see a specialist.

These are the referral requirements for each section of Medicare:

  • Medicare Part APhone AIt is the part of Medicare that covers the costs of hospitalization and hospital treatment. If you have Medicare Part A as part of Original Medicare and not through a Medicare Advantage plan, referrals are not required for specialist treatment.
  • Medicare Part B part BIt is the outpatient part of Medicare. If Part B is part of Original Medicare, you don't need a referral from your PCP to see a specialist.
  • Medicare Teil C (Medicare Advantage). advantageThe plans are offered by private insurance companies and cover the inpatient and outpatient costs of Medicare Parts A and B, plus other optional benefits. While these plans are designed to give you more choices in your health care, they often come with more limitations. Some types of Medicare Advantage plans require referrals for specialist care or certain other services.
  • Medicare Part D Part DIt is the part of Medicare that pays for your prescription drugs. These plans are not required, but they can help offset the cost of your medications. Covered drugs are based on tiers and other rules set by the plan and the insurance company. Each drug requires a prescription, but referrals are not required for Part D.
  • Medicare Supplement (Medigap). MedigapPlans have been made to cover any expenses you may incur after your basic Medicare plan has paid its share of your medical expenses. Medigap plans only cover the cost of Original Medicare, not any additional or optional benefits. Referrals are not part of Medigap.

What types of Medicare Advantage plans require referrals?

(Video) MEDICARE Referrals Can Be This Easy

Medicare Advantage plans are run by private insurance companies, and the types of plans they offer vary.

In general, Medicare Advantage plans are divided into several types, each with its own referral rules. Below is a list of some of the more common types of Medicare Advantage plans and their referral rules:

Pläne der Health Maintenance Organization (HMO).

planes HMOThey are private insurance plans that typically limit where you can get care to a specific network, with the exception of emergencies and emergency care. Some HMO plans may allow you to receive care outside of their network, but these services may cost you more.

These plans also generally require you to select a PCP from the plan's network and receive referrals for specialty care from that doctor. Most HMO plans make some exceptions for more standard specialty services, like mammograms.

Preferred Provider Organization (PPO)-Pläne

planes PPOis it sosimilarto HMO plans, as they are offered by private insurance companies and offer the best coverage if limited to doctors and hospitals within the plan's designated network.

The big difference is that PPO plans don't require you to select a specific family doctor and they don't require referrals for specialty care.

As with HMO plans, you pay less to see specialists within your plan's network than specialists outside the network.

(Video) Medicare Supplements - Medicare Supplement Coverage: Do I Need a Referral?

Private Fee-for-Service (PFFS) Plans

planes PFFSThey are private plans that generally offer more flexibility than some other Medicare Advantage plans. They also have fixed prices, which means that the plan only pays a certain amount for each service.

It is up to each physician or provider to accept this fee for reimbursement. However, not all doctors accept this fee, or they may accept the plan's fee for some services and not others.

While PFFS plans are more restrictive for providers in terms of the fees they pay, they are generally more relaxed for members. These types of plans generally don't require you to choose a family doctor, stick with a particular network of providers, or get referrals for specialty care, as long as your doctors agree to the fixed price the plan offers.

Special Needs Plans (SNPs)

SNPThey are a type of private insurance plan offered to people with very specific illnesses or medical conditions. Plan coverage is established to meet the needs of members based on their particular medical condition.

These plans generally require you to select a family doctor and obtain referrals for specialized treatment.

What if you need a transfer?

(Video) 5 Ways to Get More Medicare Referrals

If you need a referral to a specialist, the first step is to see your GP.

Sometimes a referral for specialty care is required when you have an illness or medical condition that requires specialized and precise treatment. Conditions that may involve referrals to a specialist include:

  • neurological disorders
  • Heart problems
  • Krebs

How to get a referral if you have a Medicare plan that requires a referral

If you need a transfer, you can count on the following steps:

  1. Your GP will talk to you about your condition and what treatment may be necessary.
  2. Your doctor will suggest that you see a specialist to address your needs.
  3. You will be offered suggestions or specialist options, with instructions on how to make an appointment. Your provider can also make the appointment for you.
  4. Your doctor can tell you what to expect at this appointment.
  5. If you decide to seek specialty care, your doctor must provide you with a written plan that explains why you need a referral to a specialist, what tests or special instructions you need before your appointment, how to make or when the appointment takes place. has been created for you, and any other information you may need to know.
  6. Similar information is also sent to the specialist and your insurance company.
  7. Make sure you know what information your plan needs to approve a transfer, if any. Ask your doctor to include any additional information that may be needed.

  • Original Medicare generally does not require referrals to see a specialist.
  • If you have a Medicare Advantage plan (Part C), you may need a referral from your doctor.
  • Always make sure your doctors are part of the Medicare program before making an appointment.
(Video) Getting Referrals as an Insurance Agent that Sells Medicare

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Can I self refer to a specialist with Medicare? ›

You don't usually need a referral for specialists if you have original Medicare. Even if you don't need a referral, you have to ensure that the doctor is enrolled in Medicare. Some Medicare Advantage plans may require referrals.

Does Medicare require prior authorization? ›

Medicare Prescription Drug (Part D) Plans very often require prior authorization to obtain coverage for certain drugs. Again, to find out plan-specific rules, contact the plan. Traditional Medicare, historically, has rarely required prior authorization.

Do you have to call every year for Medicare? ›

A short answer to this question is no. If you're enrolled in Original Medicare (Parts A and B) or a Medicare Advantage (MA) plan, your plan will renew automatically.

Does Medigap require a referral? ›

Does Medigap require referrals? Medigap plans, also known as Medicare Supplement Insurance, are private insurance plans that help cover your out-of-pocket costs. Due to the nature of these plans, specialists won't apply in any way, and you don't need a referral for any part of Medigap.

Does AARP Medicare complete require referrals? ›

If you have to see a specialist, you'll usually need a referral from your primary care doctor. Most AARP Medicare Advantage plans have a few exceptions to this rule. If you need flu shots, vaccines, or preventive women's healthcare services, you may receive them from a specialist without a referral.

Why will my doctor not refer me to a specialist? ›

Perhaps it's because your doctor thinks he/she adequately understands your symptoms and doesn't believe there is cause for concern. Or, maybe you require a procedure he/she thinks can be sufficiently managed by your primary care practice.

Can you lose Medicare once you have it? ›

When you turn 65, you qualify for Medicare and it's yours for life. However, there is only one circumstance in which you would lose Medicare coverage, and that's if you don't pay your Part B premium. If you qualify for Medicare due to a disability, there are some circumstances in which you could lose coverage.

Does my Medicare automatically renew? ›

Unless you take action to change it during the Annual Enrollment Period, your current Medicare coverage will renew for the following year. Automatic renewal helps ensure that you will have continuing coverage.

What happens if you don't want Medicare at 65? ›

Medicare will not force you to sign up at 65, and you'll get a special enrollment period to sign up later as long as you have a group health plan and work for an employer with 20 or more people.

What is the downside to Medigap? ›

Some disadvantages of Medigap plans include: Higher monthly premiums. Having to navigate the different types of plans. No prescription coverage (which you can purchase through Plan D)

Is Medigap more expensive than advantage? ›

On the other hand, a Medigap plan is more expensive than Medicare Advantage, but it may provide better coverage for your medical costs. This makes Medigap a good deal for those with chronic illnesses or those who need expensive medical procedures.

What is the difference between a Medicare Supplement and a Medigap plan? ›

Medicare Supplement and Medigap are different names for the same type of health insurance plan – you can use either name. To explain the terms themselves, you can think of “Medigap” as a plan that fills in some of the “gaps” for benefits that Original Medicare (Part A and Part B) doesn't cover.

What services does Medicare require prior authorization for? ›

The services most often requiring prior approval are durable medical equipment, skilled nursing facility stays, and Part B drugs. But, each Advantage plan is different. If you have an Advantage plan, contact your plan provider to determine if or when prior authorization is necessary.

Does Medicare require preauthorization for MRI? ›

MRI scans are not covered under Medicare if there is no prior authorization from a doctor or if the order was not received from your healthcare provider. Additionally, if the facility providing the MRI scan does not accept Medicare, the service will not be covered.

Does AARP Medicare require prior authorization? ›

Most Medicare Advantage plans, also offered by private insurance companies with Medicare approval, require prior authorization for some prescriptions you take and drugs administered in your doctor's office.

What Medicare does AARP recommend? ›

AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare.

What is the difference between Medicare and AARP Medicare Advantage? ›

Unlike original Medicare, Medicare Advantage plans have an annual maximum out-of-pocket spending limit for services covered under parts A and B, which must be $7,550 or less for in-network health services in 2022 and $11,300 or less for in-network and out-of-network services combined.

How much does AARP Medicare Complete cost? ›

Membership costs are minimal at only $16 per year. Costs for AARP Medigap insurance vary widely, ranging from about $60 to $300 per month. Getting a price quote based on your situation can help you understand if an AARP policy is the best deal for you.

What to do if doctor refuses to give referral? ›

You can ask them why they will not refer you and request they reconsider. If they still refuse, you may want to think about finding another primary care provider who is a better fit. Your health and well-being deserve the best care possible.

Should I go straight to a specialist? ›

But is it a good idea to go straight to specialty care first? Generally not. Your primary care provider is usually the best person to see when there's a new health issue. A primary care doctor, or general practitioner, is the person you should see for most preventive care and health concerns as they arise.

Why do specialists decline referrals? ›

Specialists may feel they must refuse a new patient when they've restricted their practice and/or the patient requires care outside the individual specialist's clinical competence or scope of practice.

At what income do you lose Medicare? ›

Qualified Medicare Beneficiary (QMB) program

You can qualify for the QMB program if you have a monthly income of less than $1,153 and total resources of less than $8,400. For married couples, the limit is less than $1,546 monthly and less than $12,600 in total.

Can I work full time while on Medicare? ›

Many people ask, "Can I sign up for Medicare and still work full time?" The answer is, yes you can. And you can have both employer health coverage and Medicare.

Can I drop Medicare Part B if I have other insurance? ›

You can disenroll from Medicare Part B and use your employer's coverage instead. You generally can't drop Part A unless you have to pay a premium for it.

How long are Medicare checks good for? ›

All checks, which reach 1 year from the date of issue and remain outstanding, must be stale dated in accordance with these instructions. Medicare contractors must document their stale dating procedures and activities as part of their written operating policies and procedures.

Can I go back to original Medicare anytime? ›

Yes, you can elect to switch to traditional Medicare from your Medicare Advantage plan during the Medicare Open Enrollment period, which runs from October 15 to December 7 each year. Your coverage under traditional Medicare will begin January 1 of the following year.

Do I need to notify Social Security when I turn 65? ›

If I want Medicare at age 65, when should I contact Social Security? If you want your Medicare coverage to begin when you turn age 65, you should contact Social Security during the 3 months before your 65th birthday. If you wait until your 65th birthday or later, your Part B coverage will be delayed.

Is Medicare free at age 65? ›

Most people age 65 or older are eligible for free Medicare Part A (hospital insurance) if they have worked and paid Medicare taxes long enough. You can sign up for Medicare Part B (medical insurance) by paying a monthly premium. Some beneficiaries with higher incomes will pay a higher monthly Part B premium.

Is Medicare free when you retire at 65? ›

Because you pay for Medicare Part A through taxes during your working years, most people don't pay a monthly premium. You're usually automatically enrolled in Part A when you turn 65 years old. If you're not, it costs nothing to sign up.

How do you ask a doctor to refer you to a specialist? ›

Follow the steps below when requesting a referral:
  1. Visit Your Primary Care Physician. Your primary care physician will evaluate your concern and, if necessary, make a referral to a specialist. ...
  2. Verify Your Insurance and Referral Information. ...
  3. Make an Appointment with the Specialist.

When can you call yourself a specialist? ›

A specialist is someone who has devoted a lot of time studying and analyzing a particular field of study and has achieved one of the highest degrees of qualification in that field. That would be a formal definition.

What are CMS guidelines for referrals? ›

If a client would like to make a referral, CMS recommends that you provide a business card for your client to give to the other person, so that person can contact you. Do not announce that you will provide gifts for referrals. When providing gifts, comply with all the rules for nominal gifts.

Can I refer a patient to myself? ›

' Importantly, though, the Stark Law does not outlaw all self-referrals, but instead bans self-referrals for procedures that will be paid for by Medicare or Medicaid, and that are considered Designated Health Services (DHS).

Who is ultimately responsible for making a referral? ›

Akin to an official recommendation, referrals are made from one physician to another. The patient is usually responsible for obtaining the original referral from their doctor. Following the request, the physician may simply write a script for treatment that references a specific doctor, such as a specialist.

What are the three types of referrals medical? ›

Modern classification of referral systems includes interval referral, split referral, collateral referral, and cross-referral.

Why would a referral be refused? ›

The referral can be rejected because it is poorly formulated or justified, ultimately because the specialist refuses to follow the request from the referring GP. This can easily lead to a relationship described as asymmetric or top-down.

Can I insist on seeing a specialist? ›

Seeing a consultant

You don't have a right to see a consultant or a particular doctor, but you can ask for this. Your GP can't insist that you see a particular consultant or doctor.

Why do you have to be referred to a specialist? ›

A referral, in the most basic sense, is a written order from your primary care doctor to see a specialist for a specific medical service. Referrals are required by most health insurance companies to ensure that patients are seeing the correct providers for the correct problems.

What is referral when it is mandatory? ›

Definition: Mandatory Referrals are plans submitted by government entities at all levels for any type of land acquisition, sale, use, or development activity.

What are 4 types of referrals? ›

With that in mind, let's look at four different types of referrals and what they mean to the success of your business.
  • Word-of-Mouth Referrals. For 85 percent of small businesses, the main method of attracting new prospects is with word-of-mouth referrals. ...
  • Online Reviews. ...
  • Social Recommendations and Sharing. ...
  • Email Referrals.

How long are referrals good for Medicare? ›

A: A referral is good for 90 days from the date of issue. If a service is required beyond 90 days, a new referral must be issued by the PCP.

Does Stark Law apply to Medicare only? ›

The Stark Law, also known as the physician self-referral law, prohibits healthcare providers from making referrals to other organizations or medical businesses in which the provider has a financial interest. The law only applies to Medicare patients seeking designated health services.

What is the process of referring a patient? ›

A specialist will only see you with a letter of referral from your GP. The letter will give the specialist essential background information, such as your medical history, and it'll also contain details that the specialist needs to pay particular attention to.

Can you have a friend as a patient? ›

A physician has to consider several issues before agreeing to see a friend as a patient. If these boundary issues are not addressed before the agreement is made, there is a risk that the physician could eventually feel resentful or exploited, and the patient could feel confused, betrayed, or even mistreated.


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