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Nov. 16, 2025

Does Medicare require referrals?

Even with Medicare, your main doctor handles most of your medical care. They can diagnose, treat, and help prevent many health issues. But sometimes, you need to see a specialist for certain conditions.

Medicare can be confusing because it has many plans and options. Once you start getting Medicare, how do you figure out what your plan covers?

Medicare is health insurance from the government for people 65 and older. It covers things like hospital stays, surgeries, treatments, and visits to your main doctor. Medicare pays for your main doctor, but do you need a referral to see a specialist?

Original Medicare (Part A and Part B) is different from Medicare Advantage (Part C). With Medicare Part A and B, you don’t need a referral to see your main doctor. But with Part C, you might need a referral, depending on the type of Medicare Advantage plan you have.

What is a referral and why would you need one?

Even with Medicare, your main doctor handles most of your medical care. They can diagnose, treat, and help prevent many health issues. But sometimes, you need to see a specialist for certain conditions.

Medical specialists are doctors who have extra training and skills in certain areas, like the heart, kidneys, cancer, bones, and more.

A referral is a medical note from your main doctor to another health care provider. Usually, you need a referral to see a specialist.

A referral is when your main doctor sends you to another doctor or health provider for special help. This can be for a specific diagnosis, opinion, test, treatment, or therapy that your clinic can’t do.

You might also need a referral if you want another doctor to give a second opinion about a specific condition.

Types of Medicare and Medicare Advantage plans that require a referral

Medicare has four parts: A, B, C, and D. Original Medicare includes Parts A and B. Part C, also called Medicare Advantage, is a different option that can give you extra coverage. Part D covers prescriptions and drug costs.

The types of Medicare are:

  • Medicare Part A is the first part of Original Medicare. It covers hospital costs, including stays in the hospital, skilled nursing facilities, nursing homes, hospice care, home health services, and mental health care.
  • Medicare Part B is the second part of Original Medicare. It covers outpatient care, which includes doctor visits, preventive services, emergency care, home health care, tests, mental health services, and rehab therapy.
  • Medicare Part C is another option instead of Original Medicare. It’s called Medicare Advantage and is offered by private insurance companies. Part C includes everything in Parts A and B, plus vision, dental, hearing, wellness, and prescription costs. Since it’s private insurance, the costs and rules can vary.
  • Medicare Part D can be added to Original Medicare (Parts A and B). It covers many prescription drugs, including most outpatient medications. Part D also covers drugs in special classes, such as antidepressants, antipsychotics, anticonvulsants, immunosuppressants, antiretroviral therapy, and anticancer drugs. These drugs help treat conditions like depression, cancer, and HIV/AIDS. Note that you can’t add Part D to Medicare Part C.

Medicare that requires a referral

If you have Medicare Part A and B, you don’t need a referral. You can see any doctor or specialist who accepts Medicare. If a doctor doesn’t accept Medicare, your appointment might not be fully covered.

Medicare Part C might require a referral to see a specialist. The specialist must accept your Medicare Advantage plan. There are three main types of Medicare Advantage plans: HMO, PPO, and SNP. You can also choose a PFFS plan.

An HMO, or Health Maintenance Organization, covers doctors, hospitals, and other health care providers within its network. If you have a Medicare Advantage HMO plan, you need a referral from your primary care doctor to see a specialist in the network.

A PPO, or Preferred Provider Organization, Medicare Advantage plan lets you see more doctors, hospitals, and specialists than an HMO. With a Medicare Advantage PPO plan, you usually don’t need a referral. But, PPO plans often have higher costs that you have to pay.

SNPs, or Special Needs Plans, are made for people with specific medical needs. If you have an SNP, you need a referral to see a specialist.

PFFS, or Private Fee-for-Service, is a special Medicare Advantage plan paid by a private insurance company and not the government. This plan lets you choose your own doctors and doesn’t need a referral. But, doctors can decide if they want to accept PFFS for each patient.

Types of medical specialists that require a referral

There are several types of medical specialists. The most common specialists are:

  • Dermatologists or skin specialists
  • Gastroenterologists or digestive system specialists
  • Cardiologists or heart specialists
  • Oncologists or cancer specialists
  • Neurologists or nervous system specialists
  • Endocrinologists or hormone and metabolism specialists
  • Orthopedic Specialists or bone and joint Specialists
  • Urologists, or urinary and male reproductive specialists
  • Rheumatologists or autoimmune specialists
  • Psychiatrists and Psychologists, or mental health and behavioral specialists

Referrals to see any of these specialists are dependent upon your private insurance company when you are under the age of 65 or without a disability.

Once you’re 65 or older, Medicare Part A and B let you see specialists without a referral. But if you have a Medicare Advantage Plan, you might still need a referral, depending on your insurance company.

What happens if you need a referral?

If you have a Medicare Advantage HMO or SNP, you might need a referral to see a specialist. Here’s what to expect when getting a referral:

  • At the end of your visit, your doctor will suggest seeing a specialist and give you a written referral.
  • Referrals have important information about you and why you need to see a specialist. This can include details about your doctor, the reasons for the referral, and your medical info, like treatments, medications, or tests.
  • Referrals are sent to the specialist and your insurance provider by your doctor. You can ask for a copy of the referral at any time.
  • The appointment with the specialist is set when your insurance and the specialist agree to cover it.
  • You will get a date to meet with your specialist.

Approval times for referrals can be different. Once approved, your referral might be open or limited. Limited referrals might say how many visits you can have, how long the referral lasts, and what treatments are included.

How long does a medical referral last?

Usually, a referral from your primary care doctor to a specialist lasts about 90 days to one year. If it needs to last longer, you might have to get it renewed. Some specialists can give ongoing referrals for long-term treatments.

Referrals are renewed for two main reasons. First, to keep your medical info, like test results and new diagnoses, updated for the specialist. Second, to make sure your Medicare coverage is current and accounts for any changes in your insurance.

What do you do if Medicare doesn’t cover medical referrals?

If your doctor gives you a referral but your insurance doesn’t cover the specialist, you and your doctor can ask your insurance company to review this.

Your insurance might or might not approve the appeal. If it’s not approved, you can either pay the costs yourself to see the specialist or your doctor can suggest a different specialist.

If the specialist doesn’t accept your Medicare plan, you can follow the same steps as if your insurance denies the referral. You can pay the costs yourself or your doctor can suggest another specialist.

Additional information for Medicare and medical referrals

The WellMed network has many doctors who can help you move from a primary care doctor to a specialist with referrals. WellMed has been offering primary care for Medicare and Medicare Advantage for over 30 years. Book your next appointment with a WellMed doctor.

Disclaimer

For full information, visit www.medicare.gov or call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week.

References

Medicare Articles