Networks & Providers
Referral
Quick answer
A referral is your PCP's authorization to see a specialist. Most HMOs require one; most PPOs do not.
Plain-English definition
Referrals are usually valid for a set number of visits or a set time period.
Why it matters
Missing a required referral can leave you paying the full cost.
A simple example
Your PCP sends an electronic referral to the plan before you see the specialist.
Common mistakes & misconceptions
Related terms
Primary Care Doctor (PCP)
A primary care doctor (PCP) is the physician who coordinates your routine care. Most HMOs require you to select a PCP and get referrals through them.
Specialist
A specialist is a doctor with focused training in a specific area, like cardiology or dermatology. Some plans require a referral from your PCP before seeing one in-network.
HMO
A Medicare Advantage HMO is a plan that uses a specific network of doctors and hospitals. You choose a primary care provider (PCP) and usually need a referral to see specialists.
Prior Authorization
Prior authorization is a plan requirement that your doctor get approval before a specific drug or service is covered. It's used to confirm medical necessity and steer to lower-cost alternatives.
Frequently asked questions
How long is a referral valid?+
Plan-specific — often 90 days or a certain number of visits.
Sources & references
📚 Where this information comes from
- Medicare.gov — official U.S. government site for people with Medicare ↗Primary source for benefits, enrollment periods, and plan comparison.
- CMS.gov — Centers for Medicare & Medicaid Services ↗Federal rulemaking, program updates, and official guidance.
- Social Security Administration — Medicare enrollment & premiums ↗Enrollment, premium withholding, and IRMAA determinations.
When you're ready, compare plans on your own terms
See Medicare Advantage plans from the insurance companies we represent, or walk the course with a licensed agent whenever you'd like a second set of eyes.
We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.
Medicare Caddies is an independent insurance agency. We are not affiliated with, endorsed by, or connected to the U.S. government, the federal Medicare program, or the Centers for Medicare & Medicaid Services (CMS). We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.