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The American Academy of Family Physicians defines a primary care physician as a doctor who specializes in being the patient’s first point of contact. In addition, primary care doctors are trained in continued health maintenance, including prevention, diagnosis, and treatment of acute and chronic conditions. If you have a Health Maintenance Organization (HMO) plan, you’ll typically be required to choose a primary care doctor, and this will likely be the physician you see most frequently.
Here’s an overview of what primary care doctors do and tips for finding one that meets your needs.
Primary care physicians for HMOs
As mentioned, primary care doctors may be involved in a wide spectrum of activities related to your care, including diagnosis, treatment, and preventive care; increasingly, a big part of their role is to educate patients about diseases they may be at risk for and ways to stay healthy. If needed, your primary care physician may also refer you to see specialists or other types of health-care providers.
Except in the case of an emergency or urgent care situation, you’ll generally need to see your primary care physician first for a referral before seeing a specialist or other health-care provider. Because this will be the doctor you have the most contact with in an HMO plan, choosing a primary care physician who fits your health needs is especially important.
How to find a doctor for your primary care from your HMO plan’s network
Whether you’re new to your HMO plan or looking to change doctors, choosing a primary care physician is an important decision that can impact your quality of care. Here are five important factors to keep in mind before deciding on a primary care doctor:
- Make sure the doctor is in your HMO plan’s network. For an HMO, you’ll need to find an in-network primary care physician in order to be covered by the plan. HMO plans typically don’t cover non-network doctors except for emergency or urgent care. If the doctor doesn’t accept your insurance, you might have to pay the bill up front, file your own claim, and/or risk not getting reimbursed.
- Choose a physician whose experience matches your specific health needs. Although primary care doctors are trained to be able to treat a wide range of conditions, they differ when it comes to specific medical experience or areas of expertise. For example, if you have certain chronic health conditions, you might consider an internal medicine physician who is specially trained to diagnosis and treat chronic diseases. If you are relatively healthy, you may prefer to visit a family practice or general practice doctor.
- Find a doctor whose location and hours are convenient for you. You’re more likely to see your primary care physician regularly if the office has a convenient location close to your work or home. If you work or have other responsibilities that make day-time or week-day appointments difficult, see if you can find a clinic with evening or weekend hours.
- Select a doctor you like. This may seem like obvious advice, but you’ll want to find a primary care doctor you get along with. Aside from the fact that he or she will be performing your physical exam, your doctor should be someone you’re comfortable discussing sensitive medical issues with. Consider whether you have certain preferences that would help you feel more at ease. Factors like gender, language, and/or bedside manner can all affect how you interact with your doctor and, ultimately, your quality of care.
Remember, HMOs require you to select a primary care physician; however, plans generally allow enrollees to switch their primary care doctor if they change their mind. Contact your insurance plan for more information on how to do this; you can find this information on the back of your membership card.
- Ask for referrals and research the provider’s feedback. Try asking friends or family members if they like or would recommend their own primary care physician. It’s usually also possible to find reviews for doctors online — although it’s always good to keep in mind that people tend to post reviews when they have a strong opinion about someone, either favorable or negative. Experiences of past patients aren’t a guarantee, but may help you have a better idea of whether you’ll be satisfied.
How to find a primary care physician in your HMO network
As mentioned, Health Maintenance Organizations (HMOs) usually require you to choose a primary care doctor in the plan’s provider network to be covered (except in emergencies). Many health insurance companies publish lists of network providers to make it easy for you to find doctors and health professionals near you. These network directories may be included in a booklet that is mailed to you or published online. If you’re not sure where to find this information, contact your health plan for help finding a primary care physician who is in your plan’s network.
Finding a primary care physician for your Medicare plan
If you have Medicare, Medicare Advantage plans are an alternative way to get your Original Medicare benefits. Just like the employer-based plans, HMO and PPO (Preferred Provider Organization) plans are some of the options you may have in Medicare Advantage. Medicare Advantage plans are required to provide coverage that is at least as good as Original Medicare, and many of them also come bundled with Part D prescription drug coverage. For some beneficiaries, these plans can offer significant out-of-pocket cost savings. HMOs are one of the most popular Medicare Advantage plan types because they strive to control costs for beneficiaries. According to the Kaiser Family Foundation, 64% of Medicare Advantage plan enrollees belong to HMOs.
American Academy of Family Physicians, “Primary Care,” accessed February 8, 2017, http://www.aafp.org/about/policies/all/primary-care.html
Kaiser Family Foundation, “Medicare Advantage,” accessed February 8, 2017, http://kff.org/medicare/fact-sheet/medicare-advantage/