Wednesday, June 15, 2022

What Is Pcp Health Insurance

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What Do Primary Care Physicians Treat?

In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 , UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

Interview Two Or Three Pcps

If you have the ability, make an appointment to meet with the PCPs you are considering. Before you speak to a potential PCP, think about the issues that are important to you. Perhaps you have some particular health concerns. Maybe you are a fan of one kind of diet, or a certain type of exercise. Ask the doctor what his or her thoughts are on these subjects. Your primary care physician should be someone that makes you feel confident and comfortable. Dont settle for anything less.

Once youve found the primary care physician youd like to use, visit HealthMarkets online to find plans that have your doctor in their networks. The HealthMarkets FitScore® can rank plans based on your needs and can help you find a health insurance plan that includes the doctor you want to use. The best part? The service comes at no cost to you.


  • Health Maintenance Organization . Retrieved from Accessed December 16, 2020.
  • Kaiser Family Foundation. Jun 06, 2019. Retrieved from
  • HMO Market Penetration And Costs Of Employer-Sponsored Health Plans. Health Affairs. October 2020. Retrieved from
  • The Right Coverage at the Lowest Price

    Health Insurance And Primary Care Physicians

    HMOs, or health maintenance organizations, often have a strict policy about referrals to specialists. This is because specialist doctors generally charge higher fees for treatment than primary care physicians.

    In order to receive approval from an HMO to visit a specialist, a preliminary visit to a general physician is usually required.

    In this case, the primary care doctor serves as a gatekeeper for the HMO, screening cases that might not really need a specialist, or offering alternate, and cheap, treatment methods than a specialist is likely to provide.

    On the other hand, PPOs, or preferred provider organizations generally allow members to visit specialists without a referral from a primary care physician.

    PPOs members can visit specialists at their own discretion, however, co-pays are often higher for these doctors than for primary care physicians. This is to encourage people to visit their primary care doctor before visiting the higher-priced specialist.

    Keep in mind that there are exceptions to these rules. If a person is injured in an accident and has a serious injury, a surgeon may be called in to operate immediately without a referral from a primary care physician, even under HMO plans.

    In this case, the emergency room doctor acts as a primary care physician, even though emergency room doctors are specialists in trauma.

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    Youll Probably Still Need Insurance Coverage

    Although direct primary care may cost less than traditional health insurance monthly premiums, the lack of coverage for other health-related expenses leaves you financially vulnerable. To prevent facing medical bills youre unable to pay, direct primary care is typically paired with one or more of the following options:

    Unitedhealthcare Dual Complete Plans

    Xpress Urgent Care vs. Primary Care Provider

    Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Call TTY 711 for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

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    You Likely Don’t Need To Have A Referral To See A Specialist

    Most EPOs will not require you to get a referral from a primary care doctor before seeing a specialist. This makes it easier to see a specialist since youre making the decision yourself, but you need to be very careful that youre seeing only specialists that are in-network with your EPO. An advantage of having a PCP is that they are often familiar with the specialists in your community, and most specialists have special interests within their specialty, for example, some general oncologists may have a special interest in breast cancer whereas another may have a special interest in lung cancer.

    And just like the “rule” about EPOs not requiring you to have a PCP, referrals can be a grey area too. The Cigna EPO in Colorado that requires PCPs also requires referrals in order to see a specialist. So again, the most important thing is that you’re familiar with the rules that apply to your specific plan, or to any plan that you’re considering as an alternative. Don’t assume anything based simply on whether the plan is an EPO, PPO, POS, or HMO!

    How To Calculate Coinsurance Payments

    With a copay, it’s easy to know how much you can expect to pay for a certain type of service or treatment. But because;coinsurance is a percentage of the service, it can be harder to predict your out-of-pocket costs.;

    The first thing you should do when trying to determine your coinsurance payment is to find out your plans coinsurance rate for the service needed.

    Some plans offer the same rate for all services. But other plans come with different coinsurance rates for different services. For example, you might be asked to pay 20% for a visit to your primary care physician, 30% for a specialist, 40% for an emergency room visit, and 15% for medication.;

    Next, find out if your coinsurance rates vary based on whether you visit a physician inside or outside of a preferred network. Some plans, such as;PPOs, may allow you to see an out-of-network provider, but may charge higher coinsurance rates.

    Finally, calculate your coinsurance rate by first converting the percentage to a decimal. A 20% coinsurance would be .20 and 35% would be .35. The calculation then looks like this:

    Coinsurance rate;x;total cost of the bill;=;your required payment

    So, if your coinsurance rate is 20% and the total cost of your doctor visit is $150, your required coinsurance payment would be $30 .

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    The Types Of Doctors That Can Be Pcps

    In the United States, primary care providers can be a physician, physician assistant , or nurse practitioner . PAs and NPs usually practice under a physician and are known as mid-level providers or physician extenders. Primary care physicians are usually family practitioners, internal medicine doctors, pediatricians, geriatricians, or obstetrician/gynecologists.

    While they’re technically specialists, many healthy women of child-bearing age see their gynecologist more often than any other doctor. They consider their gynecologist to be their PCP, and the Affordable Care Act protects this choice.

    As a result of the Affordable Care Act , women are not required to receive a referral from another doctor to see an OB/GYN. Referrals from an OB/GYN must be treated as acceptable in terms of specialist referrals required by managed care plans). Essentially, the ACA allows a woman the option to select an OB/GYN as her PCP.

    What Is A Primary Care Doctor

    What is a PCP? | Healthcare Revenue Cycle

    It may not be obvious, but the way healthcare works has changed quite a bit. Nowadays we have all sorts of specialists to deal with specific problems divided by gender, organs, age, etc. But families used to have family doctors who dealt with everything. These family doctors knew the medical history of all the adults and children in the family, and they were consulted for any medical concerns.A primary care doctor greatly resembles that tradition of having one medical practitioner handle all basic medical needs. Types of doctors that commonly serve as primary care practitioners:

    Keep in mind that your pediatrician may have a slightly altered schedule, so make sure to check with him or her for specifics, and do not rely on this article for medical advice.

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    Is My Primary Care Doctor Important

    Youve probably heard primary care doctor or primary care physician tossed around before, but maybe youve never gotten a clear definition or understood what role this type of doctor plays in your personal health. Lets look at why a primary care doctor can be extremely important, how to choose one, and what kinds of plans require a primary care doctor.

    How Do I Select My Pcp

    The most important steps are to understand your network and choose a physician thats in-network. You can find this information in the comprehensive lists of approved services and providers. If youre not sure, know who to ask. Reach out to the benefits specialist at your job or contact GoHealth and speak to a licensed insurance agent.

    Next, be sure to check with your preferred doctors office to make sure they are accepting new patients; if not, youll need to select another doctor and wait until your desired PCP is accepting new patients.

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    Which Doctors Qualify As Primary Care Physicians

    There are many specialties in medicine, but typically only four qualify as PCPs. These include:

    • Family practice or general practice doctors: A family or general practitioner is qualified to care for the entire family. Family or general practitioners can be board-certified and have training in a variety of areas including Obstetrics and Gynecology, Pediatrics, Internal Medicine, or Psychiatry. Doctors of this sort were more common in years past but can still be found to treat the entire family.
    • Internal medicine doctors: Also known as internists, internal medicine doctors are specifically trained in diagnosis and treatment. Unlike family practice doctors, internists usually only see adult patients. An internist is not a surgeon. There are several sub-specialties an internist can have. Some may specialize in a particular organ, like the lungs or the kidneys; or a particular disease, like diabetes; or a particular age group, like the elderly.
    • Pediatrics: A pediatrician specializes in the care of;children. Most treat children from birth until adolescence., and some can have sub-specialties such as surgery or pediatric cardiology. Pediatricians only serve as primary care doctors for children. Please note that health plans may have rules on age limits for patients treated by pediatricians. Age limits may range from 18 to 21 years of old. Check with your plan for specific details.

    Direct Primary Care Continues To Grow

    What is Primary Care?

    The American Medical Association states that in 2015, there were 141 direct primary care practices operating at 273 locations in 39 states. Of these, 82% posted cost information online. The average monthly cost was $93.26 and almost a quarter of the practices also charged a per-visit fee ranging from $5 to $35.

    Currently, there are over 1,000 practices participating in direct primary care in 48 states plus Washington D.C. And experts expect those numbers to continue to grow.

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    Insurance 101: Talking Health Care

    Choosing a medical plan is the first step in making sure you have access to the care you need, when you need it. An essential second step is making sure you know what terms like deductible, copay and total network out-of-pocket maximum mean so you can make fully informed decisions about your health care.

    What Is Commercial Health Insurance

    Private companies or nongovernmental organizations issue commercial health insurance. Government-sponsored health insurance policies generally are reserved for specific groups, such as senior citizens, people with low incomes, disabled people, current military members and their families, veterans, and members of federally recognized Native-American tribes. Examples of government-sponsored insurance include the Indian Health Service , Medicare, Medicaid, the State Childrens Health Insurance Program , TRICARE, and the Veterans Health Administration program. These government programs, funded primarily through taxes, are designed to provide medical coverage without returning a profit.

    In contrast, most commercial insurance providers are for-profit companies, although some operate as nonprofit organizations. Policyholders monthly premiums fund commercial policies. Their premiums and coverage amounts are designed to create a profit for the insurance company. If your healthcare policy is not part of one of the aforementioned government programs, it is a commercial health insurance policy. Employer-provided group health insurance policies are commercial, as are individual policies people can buy if they do not receive employer or government insurance benefits.

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    What Is Hmo Health Insurance

    HMO health insurance is health coverage that is offered by a health maintenance organization, or HMO. This type of health insurance is considered to be a subset of prepaid medical services in which members of the organization can obtain medical services from a select group of physicians and health care facilities. The structure of most HMO health insurance options is different from other medical insurance options in that the coverage is only valid when the member utilizes the services of doctors and facilities that have a contractual arrangement with the organization.

    The goal of HMO care in general is to provide affordable and competent medical services to as many people as possible. At the same time, the structure of HMO health insurance is also designed to eliminate spurious treatments, tests, and other factors that often drive the cost of medical care upwards. These two primary goals helped boost the appeal of HMO health insurance in the United States during the 1970s, prompting a number of companies to switch from more traditional health insurance options to an HMO plan.

    Types Of Primary Care Physicians

    What is primary health care? Why is it important?

    All primary care doctors must complete medical school and training. PCPs also choose their own primary care specialties. Some of the most common specialties include internal medicine, family medicine, pediatrics, and emergency medicine. That means that a few different types of doctors â sometimes with varying titles â are qualified to be your primary care physician.

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    You Will Be Required To Get Pre

    Your EPO will likely require you to get permission for some services, especially those which are most costly. If a particular service requires pre-authorization and you dont get it, your EPO can refuse to pay. The services which require authorization are elective and not emergency services though, so a small time delay will not be life-threatening.

    Pre-authorization helps your EPO keep costs down by making sure you really need the services you get. In plans like HMOs that require you to have a primary care physician, your PCP is responsible for making sure you really need the services you get. Since your EPO likely doesnt require you to have a PCP, it uses pre-authorization as a mechanism to reach the same goal: the EPO only pays for things that are truly medically necessary.

    EPO plans differ as to what types of services must be pre-authorized. Most require pre-authorization for things like MRI and CT scans, expensive prescription drugs, surgeries, hospitalizations, and medical equipment like home oxygen. Your EPOs Summary of Benefits and Coverage should tell you more about the pre-authorization requirement, but you should expect that any expensive service will need to be pre-authorized.

    Get The Most Of Your Time With Your Pcp

    • Be honest. Its always the best policy, especially when your health could be affected.
    • Come prepared. Write down your questions and be specific about what you intend to discuss.
    • Prioritize your concerns. Time is limited with a provider so focus on the issues most important to you.
    • Dont be afraid to request another appointment. If you have a long list of items, schedule another appointment, and tell the doctor you have other issues to address.
    • Bring someone with you. A close friend or family member can help keep track of information and is a way to be sure all your questions will be answered.
    • Use an online patient portal to communicate if available. Dont underestimate the power of communication that is not face to face.
    • Tell your doctor about OTC medications, herbal supplements, and vitamins. Some of these can interact with prescribed drugs.
    • Tell the doctor if you are stressed, depressed, or abused. Doctors may not be therapists but theyve heard it all. Dont be afraid to discuss personal issues.
    • Let your doctor know if you have reasons for not following orders. Does your medication cause side effects? Are you unable to follow a nutrition or activity plan? Let your doctor know!
    • Tell your doctor if you cant sleep. Sleep is important to your health. Your doctor can evaluate the problem and provide advice on how to solve it.
    • Let your doctor know if you have low energy. Fatigue is associated with many illnesses. Let your doctor know if this is a chronic problem.

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    How Do I Find A Primary Care Physician

    Most health insurance plans have a list of primary care physicians in your area. If you have HMO health insurance its critical to choose a primary care physician approved by your health insurance company.

    Primary care physicians often work as part of a large practice. Because of the volume of patients who visit primary care doctors, and the lower fees charged for these services, it makes sense for general practitioners to be part of a group practice.

    Some primary care physicians who specialize in certain sub-groups have special names.

    For example, pediatricians, who see only children, are considered primary care physicians even though there see only children under the age of 18.

    Gerontologists take care of the elderly;but are still considered primary care physicians. Some primary care physicians may also limit their practices to exclude certain groups, such as children or the elderly, although most general practitioners treat patients of all ages.

    Finding a primary care physician you can trust is key! Use our;FREE online tool;to compare affordable health insurance plans today!

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