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Covered California Forces PPO’s to Assign Primary Care Physicians

by John Hansen

Californians enrolled in PPO’s are concerned, but do they really have anything to fear?

For many die-hard PPO lovers, this sounds like the sky is falling. Oh, no you’re not! I chose a PPO because I didn’t want someone else to pick my Primary Care Physician (PCP).

I didn’t want to get babysat by an HMO. That’s the whole reason I chose a PPO in the first place. I’ll make the choice regarding who my doctor is thank you very much.

What’s everyone afraid of?

A lot of fears have surfaced since Covered California made this decision:

  • What if they assign me a doctor I don’t want?
  • I already have a doctor, and I don’t want to change.
  • Are they turning the PPO’s into HMO’s?
  • Do I have to get a referral from my PCP to see a specialist?

No, your PPO is not turning into an HMO.

Yes, you’ll get assigned a doctor, but you don’t ever have to see that doctor, and you can go see a specialist or another doctor without a referral from your assigned doctor. You don’t have to ever see your assigned doctor, and you can change doctors any time you want.

Also, carriers are going to try to assign you to the doctor that you’ve already been seeing if they can. This will help avoid unnecessary confusion on the part of the consumers and the doctors. But getting the systems in place to harvest this information could be difficult for carriers like Anthem and Blue Shield.

Carriers are wrestling with ways of assigning people to the PCP’s that they already have chosen. Systems must be set in place for gathering this information from clients. Blue Shield of California is considering asking for current doctor information when clients apply direct through Blue Shield. However, if they enroll through the Covered California Exchange, that won’t be an option at least not right away.

Why is Covered California forcing carriers to assign PCP’s?

Too many California consumers are getting enrolled and never choosing a primary care physician. They’re not going in for their check-ups and getting their labs done.

Part of the reason is that new enrollees are not sure how to find a doctor that accepts their coverage. Assigning a PCP to everyone makes sure that all members have a doctor right away. They don’t have to stick with that doctor, but if they want to they can.

Right away they have a physician who accepts their insurance. They have a name and phone number on the fridge. They have a doctor who they can go to if they get sick or want to get their check-ups done.

To keep rates affordable and to achieve the goals of the Affordable Care Act (ACA), government officials knew from the start that this would require a population that is getting healthier and catching health problems earlier. From the beginning of Obamacare, many preventative tests were included for free in the coverage. However, if clients are not choosing a primary care physician and getting these tests done, it isn’t going to help even though the tests are free.