Primary Care Physician

What is it?

For those enrolled in a PPO (Preferred Provider Organization) or EPO (Exclusive Provider Organization) plan, beginning January 1, 2017, your health insurance company will match you with a Primary Care Physician (PCP). Once your PCP has been matched, you will be able to change to another physician at any time you choose.

Why is this feature being added?

Covered California is working to improve the way health care is provided. PPO/EPO's may be the best choice for you if you want full access to a wide range of providers WITHOUT consent or referral from a PCP, but finding the right provider can be difficult and confusing. Your PCP will be an advocate for you, helping you to navigate the health system when you need assistance selecting the proper specialist, coordinating your care with other providers or ensuring you understand your treatment options. While having a PCP is important, you can choose to navigate the health care system on your own and you do not need permission from your PCP to seek treatment or a referral to see a specialist.

Research shows that having a relationship with a PCP is important to your overall health and well-being. Having a PCP means you will have someone you can turn to for health care advice — whether it’s preventive care, treating common illnesses and injuries, or recommending a specialist when you need one.

Rest assured, having a PCP does not change your PPO/EPO, but is an added feature. You may still access any provider, inside or outside the network for PPO’s and inside the network for EPO’s, and do NOT need a referral to access specialists.

What do you need to do?

When you renew your plan, your health insurance company will match you with a PCP, in part and when possible, based on the physician you have been seeing. If you have not been seeing a specific physician or are renewing with a new health insurance company, that company will match you with a physician as near to your home as possible. You can change this match AT ANY TIME by contacting your health insurance company.

If you have questions, please call our Service Center Monday – Friday between 8 a.m. – 6 p.m. at (800) 300-1506 (TTY: [888] 889-4500).

Frequently Asked Questions

What will happen once I am matched with a PCP, how will I be notified, what do I need to do?

You will be matched with a PCP based on the PCP you have been seeing most frequently. Or, if you are a new member, a PCP will be matched based on your location, gender, language and ethnic preferences if provided. You will be notified in writing of your matched PCP after January 1, 2017 and will be able to contact your plan to change your PCP after that time.

Will my medical history be sent to this new PCP?

No, but you can request medical records be forwarded to your PCP once a relationship has been established.

Will my PCP reach out to me initially or after an event such as hospitalization?

PCPs will only reach out to you after a relationship is established.

Can I choose my own PCP during renewal or open enrollment?

Some health insurance companies will allow PCP selection during renewal and open enrollment, but not all. Please call your health insurance company to ask if you can select or change your PCP.

I already have a PCP, and I do not want to switch. Can I keep my current PCP?

Yes, in most cases and here’s how it works: Your health insurance company will match you with a PCP that is in its network. If you are currently covered by the health insurance company that you will have for 2017, it will try to match you to a PCP you have seen before, if the PCP continues to be an ‘in network’ physician. Your health insurance company will provide directions on how to make a change to your PCP. Keep in mind, not all physicians (such as specialists) are eligible to be identified as a PCP, however you can access care from any provider in the network.

Am I required to see the recommended PCP?

No. While you may schedule an appointment at any time with your PCP, you are not required to see the recommended PCP. Covered California believes that the relationship you build with your PCP is important to your overall health and well-being. Having a PCP means you have someone you can turn to for health care advice — whether it’s preventive care, treating common illnesses and injuries, or recommending a specialist when needed.

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