ISMA is opposing and closely monitoring newly released information regarding certain Medicare Advantage (MA) plans. It requires a referral from a primary care provider (PCP) to access certain specialty care services. ISMA
signed an advocacy letter that the Indiana Hospital Association (IHA) sent to United Healthcare (UHC) on Monday, in opposition to the
referral policy. Several other specialty physician organizations also signed.
The referral is currently limited to HMO products, but could be expanded to PPO products, which could cause significant backslide in efforts surrounding prior authorization efforts. The 2026 UHC referral requirement creates a
triple pressure point:
1. Operational
• New workflows, staff training, referral tracking systems
2. Financial
• Denial risk with zero patient liability fallback
3. Clinical
• Delays, disrupted care continuity, and access barriers
"This is yet another policy that places barriers between a patient and their medical needs," Ryan Singerman, DO, FAAFP. "Healthcare decisions should be solely in the hands of patients guided by their physicians, who are duty-bound to provide safe, quality, and ethical care. Legislation, insurance, and business practices that interfere with this relationship should be condemned."
Beginning January 1, 2026, most patients enrolled in UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will need a PCP referral before seeing certain specialists in outpatient, office, or home settings.
- Referrals must be submitted by the PCP prior to the visit
- Can be backdated up to 5 calendar days
- Become effective immediately upon submission
Services That DO NOT Require a Referral
Provider Types (No Referral Needed)
- Primary Care Providers (PCPs)
- Mental Health Providers
- OB/GYN
- Chiropractors
- Audiologists
- Oncologists / Hematologists
- Nuclear Medicine / Radiology / Therapeutic Radiology
- Neonatology
- Emergency Medicine
- Nutritionists
- Podiatrists
- Optometrists / Ophthalmologists / Opticians
- Infectious Disease Specialists
- Urgent Care Providers
Services (No Referral Needed)
- PT / OT / Speech Therapy
- Cardiac & Pulmonary Rehab
- Anesthesia (Note: pain management by anesthesiologist DOES require referral)
- Home Health Services
- Observation Services
- Pathology & Inpatient Consults (including hospitalists)
- Emergency Room & Ambulance Services
- Orthopedic urgent care (acute injuries)
- Telehealth Services
- Preventive Services (Medicare-covered)
- Routine Physicals, Vision, Hearing Exams
- Dialysis
- Lab & Diagnostic Testing (including mammograms, colonoscopies)
- DME, supplies, prosthetics, Part B drugs
- Supplemental benefits (e.g., dental, vision, fitness, Rx drugs)
Services Requiring a Referral (not all-inclusive)
- Allergist
- Dermatologist
- Neurologist
- Neurosurgeon
- Orthopaedist1
- Otolaryngologist
- Plastic surgeon
- Colon & rectal surgeon
- General surgeon
- Thoracic surgeon
- Urologist
- Anesthesiologist2
- Rehabilitation medicine3
- Cardiologist
- Gastroenterologist
- Nephrologist
- Rheumatologist
- Endocrinologist
- Vascular surgery
- Pulmonary disease
- Pediatric specialist4
- Internal medicine specialist4
1 Orthopedic urgent care does not require a referral
2 Anesthesiologist only requires referral for pain management office visits
3 Rehabilitation Medicine, or physiatry, requires a referral
4 Pediatric and Internal Medicine Specialists require referrals
Important Clarifications
- No referral required for exclusions listed above—even if plan documents suggest otherwise
- Same specialty, same TIN: One referral covers all providers under that group
- Delegated providers may have different rules
Key Dates & Enforcement
- Jan 1 – April 30, 2026:
- No claim denials for missing referrals (grace period)
- Providers should begin submitting referrals
- Starting May 1, 2026:
- Claims WILL be denied if referral is missing
- Provider liability applies (cannot bill the patient)
When Claims May Still Be Denied
Even with a referral:
- Service is not covered under the patient’s plan
- Prior authorization was required but not obtained
Plans Excluded from Referral Requirement
Referral rules DO NOT apply to:
- Institutional Special Needs Plans (SNPs)
- Erickson Advantage Plans
- Michigan Integrated DSNP (H2247-005)
Identifying When a Patient Has a Referral Plan
