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Primary Care Physicians and Your California HMO Health Plan

Jul 31, 2008
First, the official definition of the Primary Care Physician:

Your Primary Care Physician ("PCP") is the doctor you choose to provide basic health care. In an HMO, your PCP must refer you to a specialist if you need to see one.

Primary Care Physician is a term that applies with HMO Plans. PPO style plans do not use PCP's. It is important for HMO members to understand how care is handled through their Primary Care Physician to get the most out of their plans.

When do you chose a PCP?

One major difference between HMO and PPO plans is that a PCP must be chosen at the time of applying or enrolling for coverage. There are usually two options for this. The first is to choose an individual doctor (Traditional Primary Care Physician) who is accepting new patients or who was your PCP under your prior plan. The other available option is to choose a contracted HMO medical group or IPA. An IPA is An independent group of physicians and other health-care providers that are under contract to provide services to members of different HMOs, as well as other insurance plans, usually at a fixed fee per patient. This usually means you may access care through this medical group and are not tied to a specific doctor as far as the carrier is concerned. The IPA may have rules on access within their group of doctors. Either way, this selection must occur before the policy can go in effect due to the structure of HMO plans.

Who do HMO applicants need to choose a Primary Care Physician or IPA?

The HMO models works very differently between the PPO model and an HMO in that the carrier pays a fixed amount to the doctor, per month for each patient he/she or the IPA has taken on under the HMO contract. The doctor is then in the position to manage the care and referrals for his/her patients under this fixed amount from the carrier. On the other hand, with PPO plans, the carrier pays per service according to the contract. There is no fixed amount. It is based on utilization.

How do referrals work with Primary Care Physicians?

Some California health carriers allow HMO members to self refer out for more common specialties such as OBGyn and dermatology. It's important to verify with your carrier or Explanation of Coverage (EOC) on how they treat referrals. In general, the trend has been towards more flexibility with HMO plans but by design, they are more structured so it's important to always double check with your carrier or PCP outside of explicitly state self-referrals, assume that all care goes through your PCP.

Changing Primary Care Physicians

Typically, you can request a change of PCP's as long as you are not in a course of treatment with your doctor. The change over usually occurs on the 1st of the month following approval of the change and the new PCP must be accepting new patients. Keep in mind that the new PCP may participate in a different HMO medical group so your choice of specialists (for referral) and/or contracted hospital may change as well.

Your choice of doctor is always an important decision but this is doubly so with a Primary Care Physician. You can research doctor choices available in each network.
About the Author
Dennis Jarvis is a licensed California broker with extensive knowledge of the Individual and Small Group health market in California. California health insurance
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