How Referrals Work With The Different Parts Of Medicare
President/CEO at Healthcare Solutions Direct, LLC, a nationwide insurance agency focused primarily on the retiree health market.
Referrals are a huge part of the healthcare system. You are able to pick your primary care physician, but then when you want to see a specialist, many Medicare Advantage companies bring the referral process into play.
This is done to ensure specialist care is actually required. A referral letter comes from your primary care doctor. It asks another healthcare professional to diagnose and/or treat a patient by specifying what type of consult or diagnostic test is medically necessary.
Referrals are also a part of Medicare Part C, although they may look a little different from what you are used to with other types of insurance.
The referral process within each part of Medicare
One out of every three patients, in the United States, is referred to a specialist each year. This means there are a lot of referrals going from primary care physician to a specialist. This process creates an extra step that can hold up your ability to schedule your next medical appointment. Sometimes a referral is not always required.
When enrolled in Original Medicare, you will not always need a referral to see a specialist. It all depends on which parts are included in your coverage, and whether or not the specialist is Medicare-approved and accepting Medicare assignments.
Medicare Part A and Part B
These are the two primary parts of Medicare that cover hospital insurance (Part A) and medical insurance (Part B.) When enrolled in either of these Parts, you do not need a referral to see a specialist as long as they are within the Medicare system.
Medicare Part C
Also known as Medicare Advantage, this is an alternative option to having Medicare Part A and Part B. It functions a little differently since it is administered by private insurance companies and not by the federal government.
Based on which Advantage plan you have, there can be specific restrictions on picking your healthcare provider as well as whether or not you need referral letters.
· Health Maintenance Organization (HMO) Plans will typically require a referral in most cases to see a specialist. Certain annual maintenance procedures, like a mammogram are exceptions.
· Special Needs Plans (SNPs) are similar to HMO plans in that you will most likely need a referral to see a specialist unless the procedure is something regularly recommended like a pap test and pelvic exam, or a mammogram.
· Preferred Provider Organization (PPO) Plans will not usually require a referral to see a specialist.
· Private Fee-For-Service (PFFS) Plans do not require referrals at all when you need to visit a specialist
Medicare Part D
Although Medicare Part D only covers prescription medications, you may wonder about whether some instances will require a drug referral. The answer is ‘no.’ You will need a prescription from either a doctor or specialist, but otherwise there is no other paperwork to worry about.
It is worthwhile to note that different medications appear in different pricing tiers within Medicare Part D. It never hurts to ask your doctor if there is a less expensive generic form of a prescription that you can take to save a little money
Medicare Supplement is offered through private insurance companies but are secondary to Original Medicare. Since Original Medicare is the insurance, there are no referrals that are required for the Medicare Supplement. The Medicare Supplement plan will just help to cover out-of-pocket medical expenses that Medicare Part A & B approved does not cover.
Getting a referral
When you encounter a situation where a medical referral is necessary under Medicare’s rules, a basic process is followed. Beginning with your primary care doctor, a few things need to happen before a specialist can confirm your appointment.
The referral your doctor writes will contain any information on recommended diagnostic tests and other specific instructions. A copy of this letter goes to the specialist as well as to Medicare, or whoever your insurance provider is.
If the insurance provider has questions, they will request additional information from your doctor before agreeing to the appointment. If it is deemed the referral is necessary, you are covered to see the specialist
Be prepared when it comes to a referral
It is good to know that not all Parts of Medicare require referrals, and that you do not always need to complete this added step when it is time to see a specialist. However, being aware of when a referral is necessary is always helpful.
Contact Healthcare Solutions Direct to understand your options
Finding the right Medicare plan for your personal needs is essential to maintaining both physical and mental health in an affordable way. While getting the right coverage is important, finding the balance between care and cost is too. Let the insurance experts at Healthcare Solutions Direct help you navigate your Medicare plan options. We represent the major Medicare carriers in the US, allowing us to pinpoint the best choice for you. After pairing you with the right plan, we walk you through the entire process, supporting you the entire way. To learn more, contact us today.
The information provided here is not investment, tax or financial advice. You should consult with a licensed professional for advice concerning your specific situation.