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Does Medicare require a referral?

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Just the essentials...
  • Medicare is the law that guarantees medical care for elderly Americans
  • Medicare has four Parts labeled A through D
  • Medicare A provides hospital care
  • Medicare Part B provides medical insurance
  • Medicare Part C offers comprehensive coverage by plans which may require referrals

Original Medicare is the name for Medicare Parts A and B. It covers hospitalization and medical insurance for beneficiaries.

The Congress added Part C to original Medicare to give seniors more choices for medical care. The Medicare Advantage Plans can cover nearly every health insurance need. They offer a wide variety of choices.

 Medicare Advantage Plans have many styles of managed care. Some use a primary care physician and referrals to utilize network specialists.

Comparison shopping can emphasize the features that matter most to a subscriber’s situation. Comparison shopping can help determine the costs of plans using referrals and those that do not.

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Original Medicare Does Not Require Referrals

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Original Medicare does not need referrals. It consists of Medicare Part A hospital insurance and Medicare Part B Medical Insurance, and beneficiaries can select any doctor that accepts Medicare payments. Using Medicare A and B, subscribers are free to consult the doctors, hospitals, and specialists of their choice.

They must determine whether the doctor or provider accepts Medicare insurance. If so, they can consult with them on the terms set by Medicare. The consumer may have to make a copayment.

Similarly, users do not need to get referrals to consult with specialists. The process repeats, and the patient must determine that the specialist accepts Medicare.

Some Medicare Part C Plans Require Referrals

Medicare Part C offers Medicare members a wide set of choices in healthcare beyond Original Medicare. Original Medicare is a public program; the Centers for Medicare and Medicaid manage the Original Medicare program. Part C consists of plans offered by private insurance companies.

The management styles vary with the insurance plans. Some insurers offer HMO plans to control costs for the consumer and promote savings on out-of-pocket expenses.

The Medicare Advantage HMO plans do not use outside referrals. The primary care physician makes referrals only to in-network resources. This structure brings consistent and low prices to the consumer.

Types of Medicare Advantage Plans

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Congress authorized Medicare Part C to bring wider choices for senior consumers. The wanted the private sector to offer innovative approaches that provided new or additional benefits and cost savings. The Medicare Advantage insurers used a number of management approaches to allocating resources.

The insurers created options that would emphasize costs, flexibility, and user choice. They include the HMO, PPO, PFFS, and HMOPOS. The below listed items describe Medicare Advantage types of plans and whether they require referrals.

  • HMO stands for Health Maintenance Organization. The HMO type of care plan requires a primary care physician and referrals for network resources
  • HMOPOS plans are health maintenance plans with the Point of Service option. The primary care physician can make referrals network resources, but also to outside resources. The insurance covers them at a higher cost to the consumer.
  • PPO, or preferred provider Organization, gives higher insurance payment for network resources and lower payments when users go outside of the network. Users do not need referrals for specialists.
  • PFFS plans, or Private Fee-for-Service Plans do not require referrals; subscribers can go to doctors that agree to the group terms.

Open Enrollment for Medicare Part C

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Medicare Part C open enrollment runs from October 15 through December 7. Some Medicare Part C plans require referrals. These plans follow the HMO or POS style of managed care.

These methods use the primary care physician to provide initial treatment and to make referrals to in-network resources.

In the case of POS style plans, the primary care physician can also make referrals to outside resources and the insurance will pay its agreed share of coinsurance. During the open enrollment period, subscribers can perform the below-listed actions on Medicare C -Medicare Advantage Plans.

  • Switch plans from a currently subscribed Medicare Advantage plan to a different Medicare Advantage plan.
  • Change from a Medicare Advantage Plan with or without referrals to Original Medicare.
  • Change from a Medicare Advantage with no drug coverage to one that has drug coverage.
  • Change from a Medicare Advantage Plan with drug coverage to one that does not have drug coverage.
  • Switch from an HMO-style plan with referrals to a PPO style plan with no referrals.

Open Enrollment for Medicare Part D

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Medicare Part D provides insurance protection for prescription drug costs. This protection in Medicare Part C, Medicare Advantage. Part D Prescription Drugs insurance can stand alone.

Some applicants prefer standalone coverage in Part D to getting a Medicare Advantage plan with prescription benefits in Part C.

Applicants must choose, they cannot have prescription coverage in both Part C and Part D. October 15 through December 7, 2016, is the open enrollment period for Medicaid Part D. Subscribers can take the below-listed actions during the Part D open enrollment period.

  • Subscribers can join a Medicare Prescription Drug plan.
  • Subscribers can switch from a Medicare Part D Prescription Drug plan to a different Medicare Prescription Drug plan.
  • Subscribers can drop or cancel a Part D Prescription Drug plan.

Open Enrollment for Medicare Part C

October 15, 2016, through December 7, 2016, is the open enrollment period for Medicare Part C and Part D. Persons with Medicare A and B or Medicare C can enroll in a new program. When considering Medicare Advantage programs, applicants can select a PPO or HMO plan.

The HMO uses referrals and a primary care physician. The PPO style of managed care does not use a primary care physician, and it does not require referrals. During the Open Enrollment period for Medicare Part C, subscribers can perform the below-listed tasks.

  • Subscribers can change from Original Medicare to a Medicare Advantage Plan.
  • Subscribers with Medicare Advantage Plans can change to Original Medicare.
  • Subscribers that change back to Original Medicare can add a Part D Prescription Drug plan

Taking Advantage of Referrals

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Original Medicare does not use referrals. Patients need referrals in some Medicare Advantage plans. Users need referrals to network resources in plans that use a primary care physician to determine the level of services.

HMO and POS plans typically use a primary care physician to administer medical services and decide when to make referrals.

The POS plans sometimes allow the primary care physician to make referrals to resources outside of the insurance plan network. Original Medicare does not use referrals, but some Medicare Advantage plans require referrals.

It is important for users to read plan terms carefully when selecting a Medicare Advantage option. Comparison shopping is a fast and effective tool for selecting a comprehensive health insurance plan in Medicare Part C or a prescription drug plan in Medicare Part D.

Find the right Medicare coverage for you and your needs today by entering your zip below.

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