| First, the official definition of the Primary Care | | | | pays a fixed amount to the doctor, per month |
| Physician: | | | | for each patient he/she or the IPA has taken on |
| Your Primary Care Physician ("PCP") is the doctor | | | | under the HMO contract. The doctor is then in the |
| you choose to provide basic health care. In an | | | | position to manage the care and referrals for his |
| HMO, your PCP must refer you to a specialist if | | | | her patients under this fixed amount from the |
| you need to see one. | | | | carrier. On the other hand, with PPO plans, the |
| Primary Care Physician is a term that applies with | | | | carrier pays per service according to the contract. |
| HMO Plans. PPO style plans do not use PCP's. It is | | | | There is no fixed amount. It is based on utilization. |
| important for HMO members to understand how | | | | How do referrals work with Primary Care |
| care is handled through their Primary Care | | | | Physicians? |
| Physician to get the most out of their plans. | | | | Some California health carriers allow HMO |
| When do you chose a PCP? | | | | members to self refer out for more common |
| One major difference between HMO and PPO | | | | specialties such as OBGyn and dermatology. It's |
| plans is that a PCP must be chosen at the time | | | | important to verify with your carrier or |
| of applying or enrolling for coverage. There are | | | | Explanation of Coverage (EOC) on how they treat |
| usually two options for this. The first is to choose | | | | referrals. In general, the trend has been towards |
| an individual doctor (Traditional Primary Care | | | | more flexibility with HMO plans but by design, they |
| Physician) who is accepting new patients or who | | | | are more structured so it's important to always |
| was your PCP under your prior plan. The other | | | | double check with your carrier or PCP outside of |
| available option is to choose a contracted HMO | | | | explicitly state self-referrals, assume that all care |
| medical group or IPA. An IPA is An independent | | | | goes through your PCP. |
| group of physicians and other health-care | | | | Changing Primary Care Physicians |
| providers that are under contract to provide | | | | Typically, you can request a change of PCP's as |
| services to members of different HMOs, as well | | | | long as you are not in a course of treatment with |
| as other insurance plans, usually at a fixed fee per | | | | your doctor. The change over usually occurs on |
| patient. This usually means you may access care | | | | the 1st of the month following approval of the |
| through this medical group and are not tied to a | | | | change and the new PCP must be accepting new |
| specific doctor as far as the carrier is concerned. | | | | patients. Keep in mind that the new PCP may |
| The IPA may have rules on access within their | | | | participate in a different HMO medical group so |
| group of doctors. Either way, this selection must | | | | your choice of specialists (for referral) and/or |
| occur before the policy can go in effect due to | | | | contracted hospital may change as well. |
| the structure of HMO plans. | | | | Your choice of doctor is always an important |
| Who do HMO applicants need to choose a Primary | | | | decision but this is doubly so with a Primary Care |
| Care Physician or IPA? | | | | Physician. You can research doctor choices |
| The HMO models works very differently between | | | | available in each network. |
| the PPO model and an HMO in that the carrier | | | | |