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What Does Pcp Mean In Health Insurance

Bottom Line On Epo Health Insurance

What Does PCP Stand For? | UPMC

EPOs have some traits in common with HMOs and some traits in common with PPOs. As such, you might consider an EPO to be a cross-breed between an HMO and a PPO: Like an HMO, you have to stay within the plan’s network. But like a PPO, you’re usually not required to get a referral from your premium care doctor in order to see a specialist.

Many people like the ease of being able to schedule an appointment with a specialist without consulting a primary care physician. At the same time, this can sometimes be a challenge in that you are limited to certain specialists within your network. Having an EPO also requires you to actively get involved in planning expensive services or procedures, and leaves you primarily responsible for completing any prior authorizations required. Overall, the combination of its low premiums and low cost-sharing make EPOs a good choice for many people. If you are finding it mind-boggling as you compare different plans, check out our comparison of HMOs, PPOs, EPOs. and POS plans.

Pcps Can Coordinate Care

Perhaps the most valuable role primary care physicians fill is also the least understood by the general public. PCPs are experts at coordinating care.

If youre healthy, this wont mean much to you. But if you develop complicated medical problems, need multiple specialist physicians, or are in and out of the hospital, youll appreciate good care coordination.

In the role of care coordinator, your PCP is the team captain. She knows what each of the specialists is doing and makes sure theyre not duplicating tests or procedures that have already been done by another specialist. Your insurance company will also do this as part of their utilization review, but having your PCP coordinating it will help to avoid denied insurance claims and needless medical services.

Do you have 20 active prescriptions from different specialists? Your PCP makes sure theyre all absolutely necessary and compatible with each other . Recently hospitalized for heart problems and now ready to start cardiac rehab? Your PCP will help keep your arthritis and asthma under control so they dont prevent you from participating in the cardiac rehab program you need.

Understanding A Health Insurance Copayment

Copayments, or copays, are a common form of cost sharing under many health insurance plans. Cost sharing is simply the portion of costs covered by you out of pocket. Splitting the cost of medical services between the insurance company and the policyholder keeps your monthly medical bills in check. If youre enrolled in coverage through a small business plan or group health insurance, your employer is typically not responsible for copayments. Copayments are usually the responsibility of the policy holder.

Understanding how this system works helps you make smartinsurance choices that suit both your health care needs and budget. Heres whatyou need to know when it comes to health insurance copays and otherout-of-pocket costs.

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What Is A Primary Care Provider

A health care professional who is responsible for monitoring an individuals overall health care needs. Typically, a PCP serves as a quarterback for an individuals medical care, referring the individual to more specialized physicians for specialist care.

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What Is A Retail Clinic

Is Your PCP Right For YOU?

A retail clinic is a space within a pharmacy or other retail store that is staffed by nurse practitioners. You can use these clinics when your doctor is not available and your injury or illness is minor, such as a sore throat, earache, or skin rash. Care at a retail clinic will cost you less than the same care in a hospital emergency room.

Please note that if you go to a retail clinic in a Walgreens or Rite Aid store, and your prescription coverage uses the Preferred Pharmacy Network, you will need to go to another pharmacy in order to have your prescription covered by your health plan. The Preferred Pharmacy Network, used by all Proactive, Silver, and Bronze plans, includes over 50,000 pharmacies, including most major chains and local pharmacies. CVS is part of the Preferred Pharmacy Network Walgreens and Rite Aid are not. Find a participating retail clinic.

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Why Do I Need To Find A Primary Care Doctor In My Plans Network

If youre enrolled in an HMO plan, youll need to find a primary care physician that is in network. Using network doctors is important because:

  • Your costs may be higher otherwise. In some cases, using an out-of-network doctor may mean paying higher medical costs or even paying the full cost for care. PPO plans are different, where your costs may be higher with non-network doctors. With an HMO, you may have to pay the entire bill if you use an out-of-network PCP.
  • Your plan may not cover you. Most HMO plans make an exception and will cover non-network doctors for urgent or emergency care. However, when it comes to your primary care doctor, youll generally need to stay in network to be covered. Check your plans rules for more information.

As mentioned, every health plan should have a list of network providers. If youre searching for a PCP, contact your health plan to make sure your doctor is covered. Or, if you have questions on whether an HMO or PPO plan might be better for your needs, an eHealth licensed insurance agent can explain the differences and work out what might be right for you.

You Likely Don’t Have To Have A Primary Care Physician

Your EPO health plan generally wont require you to have a primary care physician , although getting a PCP is still a good idea.

But the “rules” for primary care under EPOs, HMOs, PPOs, and POS plans have evolved a bit over time, and tend to be somewhat fluid. Here’s an example of an EPO plan, offered in Colorado by Cigna, that does require members to have a PCP.

So the only real “rule” is that you need to pay close attention to the specific details for your own plan. It’s true that most EPOs don’t require you to have a PCP. But don’t assume that yours doesn’t!

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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 . Medicare.gov. Retrieved from https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/health-maintenance-organization-hmo. Accessed December 16, 2020.
  • Kaiser Family Foundation. Jun 06, 2019. Retrieved from https://www.kff.org/medicare/fact-sheet/medicare-advantage/
  • HMO Market Penetration And Costs Of Employer-Sponsored Health Plans. Health Affairs. October 2020. Retrieved from https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.19.5.121?journalCode=hlthaff
  • The Right Coverage at the Lowest Price

    How Do You Choose

    What is a PCP? – HealthTexas Medical Group

    Here are the five factors to weigh before you pick a plan:

    1. How much premium can you afford each month?

    Pick a plan with an affordable monthly premium. If you cant manage your premium each month,you wont have continuous coverage and will be at risk for potentially high medical bills.

    2. How much can you afford to pay out of pocket, if you or your family needs a lot of medical services?

    Ask yourself if you have enough savings to pay the plans entireout-of-pocket maximum if the worst happens. Otherwise, you will again face potentially unaffordable bills.

    3. Do you travel outside of the plans service area?

    For example, do you visit relatives in another state, or county, or even zip code that is out of the geographic area the policy covers? Know those boundaries. And double-check your policys definition of the emergency services the plan covers. Stuff happens.

    4. Is your primary doctor in-network? If not, are you willing to change doctors?

    If your primary doctor isnt in-network, you can ask that doctor what insurance he or she accepts and go from there. Or you could decide to shop around for a new primary doctor that youd be willing to see regularly.

    5. Are your specialists in-network?

    Your relationship with your specialist may be what is keeping you healthy. Its crucial to pick a plan that offers the best doctors for your conditions.

    An HMO, also known as a Health Maintenance Organization, is one of the most common types of insurance plans.

    Limited Network

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    How Does Commercial Health Insurance Work

    When you purchase a commercial health insurance policy, you choose a plan which covers the services you need and has a monthly premium you can afford. When choosing a plan, consider the deductible. This is the amount you must pay in that calendar year before the insurance will pay its portion. A lower deductible is typically offset by higher monthly premiums, and vice versa. Look on your insurance card or contact your insurance provider to learn the total amount of your annual deductible.

    The exact services and amounts covered by commercial health insurance vary depending on your policy, but in general, they pay for a significant portion of the covered persons medical expenses. Elective procedures which are not deemed medically necessary usually are not covered. Qualifying expenses include routine medical care, doctor visits, hospital stays, emergency services, mental and behavioral health, substance abuse treatment, and preventive services.

    Preventive services are are performed regularly to prevent or detect potential health issues early, so they can be avoided or treated before they become more serious. Commercial health insurance plans cover many preventive services at no cost to the patient. These services may include routine immunizations, screenings, annual well woman exams, mammograms, and counseling.

    How To Search For An In

    • Log in to the myCigna® website to search for an in-network provider. The provider directory on myCigna.com shows you results based on your health plan network and your location.
    • Know before you go. Before you visit any provider or facility, we recommend you to be sure they are in your plans network, as well as confirm their address, office hours, and that they are accepting new patients.
    • Meet the provider in person. Ask to schedule an introductory appointment. This appointment can help you decide if the provider is a good fit for you.

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    Choose Coordinated Care For Better Health

    We’re here to help you and your family get the best and most affordable care and support you on your health journey. Thats why our health plans give you access to coordinated care.

    Why is coordinated care better?

    With coordinated care, your primary care provider is responsible for making sure you get all of the care you need not just the care they can provide. If you need to see a specialist or go to the hospital, they will coordinate that care for you and work together with your other providers.

    With traditional care, you are responsible for making sure you get all of the care you need. This includes the preventive services that will help you stay healthy. Also, providers most often work separately, which means that each may not know about all of your health history.

    With coordinated care, you get:

    • A primary care provider who uses a team-based approach and who will be responsible for making sure you get the personalized care and services you need
    • Faster, easier ways to get care
    • Extra support to help you reach your health goals
    • An estimated overall cost savings as a result of keeping up-to-date with preventive care

    Moda Health is the only health plan that provides access to this kind of high-quality care.

    American Disabilities Act Notice

    What Does Pcp Mean In Health Insurance

    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.

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    Why Should You Choose A Primary Care Physician

    Dont wait until you get sick to choose a PCP. Primary care physicians typically prefer to see their patients regularly and look for symptoms a patient may not notice.

    For example, a routine health exam may uncover conditions such as high blood pressure or even hormonal imbalances due to glandular problems. Health problems like these can go unnoticed by the patient for years and could result in serious chronic health issues. Annual exams with your PCP may guide you toward healthy lifestyle habits and help you catch serious conditions early, when they are more easily treated. One of the most important jobs of a primary care doctor is preventive care: keeping you from getting sick in the first place. Seeing your PCP every year reduces the likelihood that youll need expensive specialty care later.

    Remember the old adage: An ounce of prevention is worth a pound of cure.

    Unitedhealthcare Dual Complete Plans

    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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    View Sample Insurance Card

    Primary and Specialist Care Coverage

    Often, the name of your primary care provider will be listed on your health insurance ID card. Many plans require you to have a PCP who coordinates your care and makes sure you stay healthy. You may choose your own PCP, or your plan might assign you one. You also can change your PCP if you choose. If you do not have a PCP, you can call your plan, or check the provider directory, to find one in your network.

    Your ID card may list your copay for a PCP visit. This also may be listed as the office visit copay. Keep in mind that many plans now offer preventive care at no cost to you, including one PCP visit each year. You can call your insurer or check with your doctor to find out what services you can get without a copay.

    You may also see a copay for specialist care. Your specialist copay will usually be more than your PCP copay. In addition to knowing the copay, its important to know your plans rules for getting specialist care. Do you need a referral from your PCP first? Does your plan need to authorize the service that you need? Will the plan pay for a specialist who is not in your network? Make sure you ask these questions before your visit to avoid any unexpected costs.

    Where You Can Get Care

    In-Network and Out-of-Network Benefits

    Your health insurance ID card can help you understand how much you will pay for care that is provided by a health provider in your plans networkand outside of it.

    What Is A Health Maintenance Organization

    What it means to work with a WellSpan primary care provider

    An individual who needs to secure health insurance may find a variety of health insurance providers with unique features. One type of insurance provider that is popular in the health insurance marketplace is a health maintenance organization , an insurance structure that provides coverage through a network of physicians.

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    Which Services Have A Health Insurance Copayment

    The rules for health insurance copayments vary based on the policy and provider. Check the details of your plans policy for more information. You may owe a copayment for:

    • Office visits with a primary care physician for non-preventive care
    • Office visits with a specialist
    • Prescriptions
    • Mental health in-office services such as physiotherapy or drug counseling
    • Ambulance or ER services

    As mentioned above, preventive care is generally exempt from cost-sharing thanks to the Affordable Care Act, so copays would generally not apply for these office visits.

    Keep in mind that your plan may have provider network rules.Your costs may be higher if you go out of network or use a non-preferred doctoror provider. If you go out of network, your copayment or coinsurance costs maybe more, or you may be required to pay the full amount for the services.

    What Is Durable Medical Equipment

    Durable medical equipment includes, but is not limited to, the following: hospital beds, crutches, canes, wheelchairs, walkers, peripheral circulatory aids, cervical collars, traction equipment, physiotherapy equipment, oxygen equipment, and ostomy supplies. You should always check with both your provider and Independence Blue Cross to determine whether an item is considered to be durable medical equipment.

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