Q.  What is a Primary Care Physician?

A.  A Primary Care Physician is trained to manage your entire health care program. Your Primary Care Physician plays many roles - primary caregiver, health care advisor and consultant, coordinator of specialty care and patient advocate.

    Primary Care Physicians can include:

• Family/General Practitioners (Doctors who treat patients of all ages)
• Internists (Doctors who treat adults and may have a subspecialty)
• Pediatricians (Doctors who treat children)
• Gynecologist (Doctors who treat women)

Q.  Can I change my Primary Care Physician?

A.   Yes, you have that option once a month. If your request is received on or before the 15th of the month, your change will be effective the next month. After the 16th, your change will take place the 1st of the second month.

Q.  What is a specialist?

A.   A specialist is a physician that focuses in one area of medicine. From cardiology to urology, a specialist is trained as an expert in his/her particular field.

As an HMO member when you need specialty care, your Primary Care Physician will refer you to, and work with, a specialist to ensure you receive proper medical attention and follow up.

Q.  What is an Express Referral, Direct Referral, or Open Access?

A.  Express Referrals is a streamline referral process offered through participating Medical Groups and IPA’s.  With these HMO referral options, members can self-refer themselves directly to specialists without any further authorization.

Q.  What are "Medical Networks" and "IPAs"?

A.   Most contracted physicians belong to either a Medical Group or an IPA. A Medical Group is a partnership of Primary Care Physicians and Specialists. These physicians share the same medical offices and are employed by the Medical Group.

An Independent Practice Association (IPA) is a just that - a group of independent physicians that have joined together to work with other health care companies. Physicians belonging to an IPA usually have their own offices, separate from other physicians in the IPA.

Q.  What is the difference between Emergency Services and Urgent Care?

A.   Emergency Services as those services required as a result of an unforeseen injury or acute illness for which a delay in treatment would result in a permanent physical impairment or loss of life.

Urgent Care, on the other hand, is defined as those services required as a result of unforeseen injuries or acute illness that require immediate attention. A broken arm may be an example of an urgent care situation. We ask that you try to contact your primary care physician in an urgent care situation and arrange your care with your primary care physician if possible.

Q.  HMO, PPO, and POS health plans. What is the difference?

A.   There are three types of managed care health plans: HMO, PPO, and POS. The basic differences between the plans are cost and flexibility in choosing a physician

   HMO

A Health Maintenance Organization is the most affordable plan Carriers offers. Health services are accessed through the Primary Care Physician chosen from the physicians listed in the HMO Provider Directory. For each office visit, you only pay your co-payment.

   PPO

A Preferred Provider Organization is a network of physicians that have agreed, by contract, to discount their rates to PacifiCare members. These "preferred providers" may be Primary Care Physicians or Specialists, and PPO members are free to see any of them. PPO members may also access non-contracted providers, but at a higher out-of-pocket cost. PPO Provider Directory for a list of "preferred providers."

   POS

A Point-of-Service (POS) plan combines the cost savings of a HMO with the flexibility of a PPO. These are both Dual Option and Triple Option POS plans.

Dual Option: If you're looking for affordability, use the "In-Network" option of your plan. Just like a HMO, make an appointment with the Primary Care Physician you have chosen from the HMO Provider Directory. You will be charged only your co-payment. If you want flexibility, choose to go "Out-of-Network." Like a PPO, you can see any of the providers.

Triple Option: This plan adds the option of seeing non-participating providers at a higher out-of-pocket cost.