Our primary care doctors help us with so many of our day to day health care needs. But what happens when we need to see a specialist? Healthcare coverage differs when it comes to referrals to specialists.
It’s important to understand when you might need to see a specialist and whether your Medicare benefits require a referral in order to see that specialist.
What Is a Referral and Who Provides Them?
If you’re a Medicare beneficiary, a referral is an order to receive treatment from a doctor who accepts Medicare and specializes in your medical issue.
Your in-network primary care doctor can provide you with specialist referrals.
Original Medicare — Parts A and B — provides nationwide coverage and access to all doctors and hospitals that accept Medicare without referrals. On the other hand, Medicare Advantage plans provide local or regional in-network coverage and may require referrals.
While Original Medicare and PPO plans require no referrals, HMO plans typically do require referrals to see a specialist . Keep in mind that out-of-network specialists generally cost more than in-network specialists.
HMO plans can cover emergency and out-of-network urgent care without referrals. However, you may have to pay for services yourself to see a specialist without a referral.
Learn more differences between HMO vs PPO plans.
You may have coverage to the following in-network services without referrals:
Routine women’s health care, including breast exams, mammograms, pap tests and pelvic exams
Flu shots and hepatitis B, pneumonia, shingles and COVID-19 vaccinations
Kidney dialysis outside your plan’s service area
Behavioral Health Services
The licensed agents at Senior Healthcare Direct can help you determine the best coverage for your health care needs. Call 1-833-463-3262, TTY 711, today, or click here to get your quote.
LEGAL DISCLAIMER: The above is meant to be strictly educational and not intended to provide medical advice or solicit the sales of an insurance product or service of any kind.