Can You Get A Referral With Medicaid?

Medicaid is a government program that helps people with low income get healthcare at little to no cost. If you have Medicaid, you might need a referral to see a specialist, get certain lab tests, or receive special treatments.

Medicaid rules are different state-to-state, so whether you need a referral depends on your specific plan. Ahead, we'll explain when you need a referral, how to get one, and how state rules may affect the process.

When do you need a referral with Medicaid?

A referral is when your regular doctor (also called a primary care provider) sends you to another doctor for more specialized care.

Often, a referral is required when a specialist or service is in-network with a Medicaid Managed Care Plan to ensure coverage. If a provider is out-of-network, Medicaid may not cover the visit, or additional approval may be needed.

Managed Care Plans

Most people with Medicaid are enrolled in a Managed Care Organization, which contracts with a network of healthcare providers. If you are in a Managed Care Organization, whether you need a referral depends on whether the provider is in-network or out-of-network:

• In-network providers: These are doctors, specialists, and facilities that have agreements with your Medicaid Managed Care Organization. Referrals are often required for specialists, diagnostic tests, and certain treatments, including dental care, behavioral health services, occupational therapy, and some family planning services. Your primary care provider (PCP) will issue the referral to ensure Medicaid covers the service.
• Out-of-network providers: Medicaid Managed Care Organizations generally do not cover out-of-network providers. Your PCP may request an out-of-network referral, but Medicaid must give prior authorization (special approval) before you receive care. Otherwise, you may have to pay out-of-pocket.

Fee-for-service Medicaid

Some states have fee-for-service (FFS) Medicaid, where Medicaid pays directly for each service instead of using a managed care network. In FFS Medicaid:

• You may have more freedom to see specialists without a referral.
• Some services, like dental, behavioral health, or therapy, may still require prior authorization.
• Rules vary by state, so check with your state Medicaid office to see if referrals are needed.

Examples of types of care that might need a referral

In many Medicaid Managed Care Plans, you may need a referral from your PCP for health care services like:

• Seeing a cardiologist for chest pain
• Getting physical therapy after an injury
• Visiting a dermatologist for a skin condition
• Seeing a behavioral health specialist for mental health treatment
• Getting dental care beyond routine checkups like orthodontics
• Accessing certain family planning services
• Receiving occupational therapy

However, some Medicaid plans allow direct access to specific services without a referral, such as:

• Preventive family planning services (e.g., birth control, STI testing).
• Some behavioral health services
• Early intervention services for children with developmental delays

Since Medicaid rules vary by state and plan, we recommend you check with your check with your primary care doctor to see which medical services need a referral.

How to get a referral with Medicaid

If you need a referral, follow these steps:

1. Make an appointment with your Medicaid-approved primary care physician.
2. Your PCP will decide if a referral is a medical necessity and which kind of specialist you need to see.
3. Your PCP submits the referral electronically or by paperwork.
4. Some Medicaid plans require prior authorization before the referral is processed.
5. Once the referral is approved, you can make an appointment with the specialist.

Before your visit, double-check that they accept Medicaid to avoid unexpected costs.

What if you don't have a referral?

If your Medicaid plan requires a referral and you see a specialist without one, you could have to pay out-of-pocket for those health care services.

However, there are some exceptions:

• Emergency services do not require a referral
• Some states allow direct access to certain specialized care, like OB/GYNs for women's health

If you need a referral but didn't get one, try these solutions:

• Call Medicaid customer service to ask about your options.
• Ask your PCP for a retroactive referral (some plans allow this if the visit was a medical necessity).
• Appeal a denied claim if Medicaid refuses to cover the visit.

A note from Givers

Medicaid referrals help ensure coverage for specialized medical services. If you're in a Managed Care Plan, a referral from your primary care doctor may be required. Out-of-network care providers usually need prior authorization or may not be covered.

Since rules vary by state, check your Medicaid plan or state Medicaid office to confirm referral requirements. Visit your state's Medicaid website or call your health plan for the most accurate information.