Do I need a referral on Medicare Advantage?

On many Medicare Advantage HMO plans (Health Maintenance Organization plans, where your Medicare benefits come through a private plan with a network), you typically need a referral, meaning your primary care doctor's approval, before you see a specialist. On most Medicare Advantage PPO plans (Preferred Provider Organization plans), you usually do not need a referral and can see specialists directly, including some out of network at a higher cost. Some HMO plans also offer a point-of-service option that allows certain out-of-network care. Because referral rules are set by each plan, the only way to know for sure is to check that plan's documents. Skipping a required referral can mean the plan does not pay, so it is worth confirming. To check the rules on a specific plan, reach out to a licensed Goodsurance advisor at 1-888-301-8091 (TTY 711), Mon to Fri 8 am to 5 pm PT.