Does Medicare Require a Referral to See a Specialist?

The majority of your healthcare needs can be met by your primary care physician, however some of your medical issues may necessitate the services of a specialist. As a patient, it is important to know when it is appropriate to see a specialist and whether or not your Medicare insurance requires you to have a recommendation in hand.

When should you see a specialist?

There is no better place to start than your primary care physician. Setting and achieving health goals, as well as setting up preventive care can also be done by them. A trip to your primary care physician is usually the initial step in addressing any acute or persistent symptoms you may be experiencing.

In order to rule out or confirm any medical disorders you may have, your primary care provider might conduct certain tests and offer you with an initial diagnosis. If you have a more complicated health issue

, they may not have the skills or experience to help you with it. As a result, your primary care physician may recommend that you see a specialist.

There are currently more than 120 medical specialties and subspecialties to choose from. For example, a branch could specialize on a single disease or an organ system or a particular organ. The number of specialists you see depends on your condition and the intricacy of your situation, so you may see more than one.

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. Original Medicare coverage should apply as long as you see a specialist who accepts assignment. A specialist who does not take Medicare means that you will have to pay for your care out of your own money if you have Original Medicare. Copays and coinsurance for specialist visits may be covered by some Medigap plans.

Referral requirements with Medicare Advantage plans

Private insurers provide Medicare Advantage plans, which must provide the same level of coverage as Original Medicare. In addition to that, they might have their own provider network, and they can have additional perks. They consist of:

• • HMO Plans – Health Maintenance Organization Plans focus on care coordination. For most health insurance plans, you must be referred by an in-network clinician to a team of healthcare specialists who work together to help you stay healthy.

  • PPO Plans – In-network and out-of-network doctors and specialists are covered under Preferred Provider Organization Plans. In-network specialists are less expensive and don’t require referrals, so it’s a win-win situation. 

• PFFS Plans – Private Price-for-Service plans don’t require a recommendation, but it’s a good idea to call the expert in question to find out their fee schedule and the insurance they accept.

• SNPs – Finally, although most Special Needs Plans don’t require referrals for basic checkups or yearly screenings by experts, many do. Non-emergency specialists must be in-network to be covered by your insurance.

Specialist costs

The average cost of a doctor’s visit ranges from $125 to $300. Specialists are more expensive, with an introductory appointment costing anywhere from $400 to $900. To cover the remaining 80% of the cost, you’ll either have to pay out of pocket or have additional insurance, if they accept Medicare assignment.