Do AARP Medicare Advantage Plans Require a Referral to See a Specialist?

The requirement to get a referral to see a specialist under AARP Medicare Advantage plans can vary greatly depending on the specific plan you are enrolled in. In my case, I am on the UnitedHealthcare AARP PPO Advantage plan, and no referral was necessary when I transferred my cardiac care to a specialist closer to home.

General Guidelines

It is important to understand that the need for a referral to see a specialist can depend on the type of Medicare Advantage Plan you are enrolled in. Some plans may require a referral, while others do not. This requirement is often part of the Evidence of Coverage (EOC) document provided by the insurer, which you can find on the plan's website or request in writing.

Refer to the EOC document if you need specific details on your plan's requirements. For example, some specialties may require a referral from your primary care provider (PCP) to ensure that the PCP has ruled out other potential causes for your symptoms before a specialist is consulted. This can be particularly relevant for those on regular Medicare or private/employer insurance plans.

Special Situations

In certain geographic areas, where specific types of specialists are rare and in high demand, some plans may require referrals from a PCP. This rule applies to both those on regular Medicare and those covered by private or employer insurance plans.

Plan Variations

The requirement for a referral can also differ between different Medicare Advantage plans. HMO (Health Maintenance Organization) plans typically require a referral to see a specialist, while PPO (Preferred Provider Organization) plans generally do not, although they may have a preferred network with different copayments. In my experience, UnitedHealthcare Advantage plans do not require a referral from a PCP to see a specialist.

General Advice

It is generally beneficial to have a primary care doctor that you trust to help guide you through these decisions. They can provide valuable insights and ensure that your healthcare needs are being properly managed.

For further details, refer to the Medicare and You 2024 handbook, which offers a user-friendly version of the EOC for Medicare recipients.