My Advantage plan says I need a referral just to see a dermatologist. I thought PPOs didn't require that - was I wrong?

Question

Antonio Espino · Accepted Answer

You are correct. PPOs do not require referrals. But there are "office policies" that require one. The insurance company can't force the practice to not require one.

Renee Brown · Answer

Yes, unfortunately you may be wrong. Even though PPO plans do not generally ask for referrals, it may depend on the state guidelines or requires and restrictions. Different states have different guidelines and therefore the Medicare Advantage company has to follow the states guidelines. It is always good to review the plan guidelines or ask your agent to assist you with making sure your plan does not have that requirement.

Answered by Renee Brown on May 12, 2025

Broker Licensed in FL, AL, AR & 32 other states

Answered by Renee Brown Medicare Insurance Agent

Steven Bleicher · Answer

Just because a PPO allows you to go both in & out of your Advantage plan's network has nothing to do with referrals. You're confusing two different principles here. Also, bear in mind that I know the State of Arizona backwards & forwards. That means that there are likely some states where the answer given above may be different. It would make sense to check with your Medicare insurance company or your agent.

Answered by Steven Bleicher on April 8, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Diana Garner · Answer

Some Medicare Advantage plans still have referral requirements. It is always a good idea to carefully review the plan documents to see if referrals are required.

Michele Vina · Answer

Although the plan may not require a referral to see a specialist, some doctor's offices may request one.

Fred Manas · Answer

Yes, it's possible that your Medicare Advantage PPO plan requires referrals for specialist visits, including dermatologists, even if it's a PPO. While PPO plans generally don't require referrals, some Medicare Advantage PPOs may have specific rules or restrictions. 

Here's a more detailed explanation:

General PPO Rule:

PPOs typically don't require referrals from a primary care physician (PCP) to see specialists. 

Medicare Advantage PPO Variations:

Medicare Advantage PPO plans can vary in their rules and restrictions, including referral requirements. 

Plan Specifics:
It's crucial to review your specific Medicare Advantage PPO plan's details to understand its referral requirements. 

Checking Your Plan's Documentation:

Look for information about referrals in your plan's Member Handbook, Evidence of Coverage, or Summary of Benefits. You can also contact the plan's customer service for clarification.
 
In-Network Restrictions:

Even if your PPO plan doesn't require referrals, you may still need to see specialists who are within the plan's network to avoid higher out-of-pocket costs. 

Potential for Missed Coverage:

If you see a dermatologist without a referral, your plan might not cover the visit, even if you're in-network.

Gary Henderson · Answer

It varies by insurance company. You would need to get an answer from them. You don't need a referral for supplement plans.

Vachik Chakhbazian · Answer

Yes, you may be wrong. some PPOs, may require referrals, even for specialists. rules can vary between different insurance companies and even between different plans offered by the same company. You might be required to use specialists within the plan's network, and some plans may require referrals to use in-network specialists.

Answered by Vachik Chakhbazian on April 20, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Deborah Webster · Answer

PPO's allow you to go to out-of-network doctors. (at a higher cost sharing) PPO's however, can still require a referral to see a specialist. To find out whether your company requires this, you should check this information in your evidence of coverage document.

Answered by Deborah Webster on April 30, 2025

Broker Licensed in Ia & SC

Answered by Deborah Webster Medicare Insurance Agent

Sean Krause · Answer

Some doctors even if in a PPO may require a referral from your PCP before they will see you. This is a function of the doctors office. Not your Medicare advantage plan.

Tommy Lawson · Answer

Usually, but it depends on the language of the plan you are enrolled in. Sometimes, even PPO plans, require referrals to dermatologists do to cost and, likely, something the plan feels your primary care physician could take care of.

Answered by Tommy Lawson on April 8, 2025

Broker Licensed in KY, CT & IN

Answered by Tommy Lawson Medicare Insurance Agent

My Advantage plan says I need a referral just to see a dermatologist. I thought PPOs didn't require that - was I wrong?

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My Advantage plan says I need a referral just to see a dermatologist. I thought PPOs didn't require that - was I wrong?

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