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Does Medicare Require a Referral to see a Specialist?

Discover which Medicare plans require a referral to see a specialist, and learn about in-network services that may not require referrals.

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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

  • Dermatology

  • 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.

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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.