Covered California Primary Care Physician Assignment Guide

Covered California has released their Primary Care Physician Assignment Quick Guide to inform agents about how health plans will be assigning a Primary Care Physician to members of PPO and EPO plans in 2017. The Primary Care Physician assignment will not apply to small employer group with Covered California health plans.

Primary Care Physician Assignment Quick Guide

Beginning January 1, 2017, Covered California health plans are required to ensure that ALL Covered California members either select a Primary Care Physician (PCP) or have one recommended by their health plan. Health plans will make a recommendation by January 1, 2017 or within 60 days of the consumer’s effective date with the health plan. If the health plan selects the PCP, consumers will be able to change to another physician at any time.

The PCP assignment only impacts the individual market and does not affect Covered California for Small Business (CCSB) consumers. This requirement may apply to CCSB in the future, but not for 2017.

Health Maintenance Organization (HMO) Plans

This new change does not impact HMO consumers since they are enrolled in HMO products are currently required to have a PCP.

Exclusive Provider Organization (EPO) & Preferred Provider Organization (PPO) Plans

PCP selection is not currently a feature of the PPO or EPO product, but will be an added feature for the 2017 coverage year. While these members will have a selected or recommended PCP, they are NOT be required to see the PCP and may continue to access specialists and other providers as they currently do now under PPO or EPO plans.

Covered California is working to improve the way health care is provided. EPO’s and PPO’s may be the best choice for consumers who want full access to a wide range of providers WITHOUT consent from a Primary Care Physician, but finding the right provider can be difficult. While having a PCP is important, consumers with a PPO plan may see in and out of network physicians without a referral and in an EPO plan, a consumer may only see in network physicians, but do not need a referral.

Added Value

Research shows that having a relationship with a PCP is important to overall health and well-being: 

• PCPs serve as an advocate who will assist with most of a consumer’s care needs ranging from preventive health and wellness to managing chronic conditions. 
• PCPs help select the proper specialist, coordinate care with other providers and ensure that consumers understand treatment plans. 
• PCPs also follow up regularly to make sure consumers are up to date on routine care such as health screenings and immunizations.

PCPs can be internal medicine doctors, family physicians or pediatricians. Members may opt to select a nurse practitioner (NP) or physician assistant (PA) as their preferred provider of primary care. Each family member can have their own PCP. Consumers with EPO & PPO plans may still access any provider within the network and do NOT need a referral to access specialists.

This new requirement represents a change in the way care is organized for PPO and EPO members is the next phase of the promise of the Affordable Care Act in that it supports the goals of the Triple Aim (affordability, access, and improved health) by facilitating a regular source of care from enrollees and bending the cost curve through better disease management and more appropriate care.

Next Steps

No action is needed at this time.

During renewal in the fall of 2016 a PCP will be selected for consumers who do not currently have one, and when possible, the selection will be based on the physician the consumers currently have. If the consumer has not been seeing a specific physician or is renewing with a new provider, a physician will be selected for the consumer that is as near to their home as possible. A consumer can change this assignment AT ANY TIME by contacting their Covered California health plan.

Consumers will either receive notification from their health plan indicating which PCP has been designated or confirmation of the consumer’s PCP selection.