When you sign up for health insurance in Texas, you must make several choices. What company do you select, what metal tier will best suit your medical needs, and which deductible will fit your financial situation? All of these choices are made simpler due to the Affordability Care Act. Once you are situated, you are faced with other choices. One of the main choices is your Primary Care Physician. You will often see this abbreviated as PCP. But what is a primary care physician?
Before we begin, we would like to introduce you to the various parts of insurance and how a Primary Care Physician impacts your medical care.
What are the Parts of Health Insurance in Texas?
Insurance plans have several pieces that work together to provide you with coverage. We would like to introduce you to a few of them.
Deductible – Deductibles are the amount you pay out-of-pocket before your coinsurance pays its portion. A deductible is one factor that determines how much you will pay per month for your insurance; the higher your deductible, the lower your premium will be; the higher your deductible, the lower your premium. Your deductible recycles at the beginning of the following year. There are many services you can receive from your Primary Care Physician before having to meet your deductible.
Coinsurance – Once you meet your plan’s deductible, your coinsurance begins. This is a cost-sharing benefit and also factors into your premium. It works on a percentage scale from 50/50 percent to 80/20 percent. You pay the lower amount. This will be determined by metal tier and the insurance company you select. You can view details in your Summary of Benefits. You pay your coinsurance until you reach your out-of-pocket maximum.
Out-of-Pocket Max: After meeting your deductible, you are working toward your out-of-pocket maximum. This is self-explanatory; it’s the most you will pay out of your pocket for your medical expenses. Once you reach this dollar amount, your policy will pay 100 percent for that individual on your policy for the remainder of the calendar year. A policy also has a family out-of-pocket max. When this amount is reached, the entire family on the policy will have medical expenses paid for the remainder of the year regardless of if they have met their individual out-of-pocket max.
Copay– Copays are fees medical providers charge for office visits. It is important to understand that a copay is for a visit alone, not for the treatment you receive. You may be charged a flat dollar amount or a percentage, which can vary by treatment, medical event, or even plan you are on. All medical plans cover well check-ups and preventive care, and you will not pay a copay when you visit the doctor for these services. You will see a copay when you visit your Primary Care Physician.
Now let’s explain how your primary care physician works in relation to the above.
What is a Primary Care Physician?
When you have an individual or family health insurance policy, you will see different types of doctors. How that doctor is labeled will depend on a few factors:
How you have chosen to label them in your insurance policy.
First, it is up to you. When you sign up for health insurance in Texas, most companies ask you to select a Primary Care Physician. This can also be known as a Primary Care Provider. Once you have chosen your PCP, many network providers require you to coordinate your medical care through them. This means that if any treatment would need the care of a Specialist, you must see your PCP first and get their recommendation for the treatment.
Who do they provide care to?
Doctors provide care to individuals and families. Doctors also have specialties like physical therapy, cancer, and neurology. These doctors are called Specialists. With a Primary Care Physician, they have a basic overall knowledge of medical conditions. When you visit them with your medical symptoms, they can assist with an initial diagnosis. Better yet, they know which medical professional to direct you to so the Specialist can better treat your medical condition.
Which facility do you see them in?
You would normally see a PCP in a medical facility, sometimes in a general practice office. This will depend on who they are contracted with. Many doctors, like with Blue Cross Blue Shield of Texas, are located near hospitals and other medical facilities.
How Do You Pay for a Primary Care Physician?
You will usually pay for your visit at the time you receive care. This is called a copay. As we defined earlier, copays give you access to be seen by a doctor before your deductible. However, some plans require you to pay a percentage of your PCP visit instead of a copay. See your plan’s Schedule of Benefits for details.
What is a 40 percent Primary Care visit medical plan?
First, as you read your Schedule of Benefits, you will see that all your benefits are percentage based. Next, when you see a percentage as a copay for your Primary Care Physician visit, it can be tied to a High Deductible Health Plan. This means you will pay 100 percent out of pocket for your visit until you meet your deductible, then you begin your cost-sharing 40 percent portion until you meet your out-of-pocket max.
These plans are not as common. Oscar Insurance has a couple of plans that are percentage-based copays.
Are there zero-dollar copays?
There are some instances where you will have a zero-dollar copay. When you visit your PCP, you can receive preventive health services without paying a copay. These include:
Adults: These will include screenings for blood pressure, diabetes, hepatitis, various cancers, tuberculosis, and STDs. It will also include adult immunizations.
Women: In addition to the adult services, birth control, breastfeeding support, diabetes, and other at-risk pregnancy screenings are included. Support for maternal depression also provided.
Children: Immunizations to age 18, well-baby/child visits, TB tests, screenings for vision, development, and autism. Regular development assessments are also conducted.
Cover Mile can help you learn about what plan best suits your needs. You can contact our agents, and we can find the insurance plan that provides coverage that includes your primary care physician.
Does My Choice of Primary Care Physician Affect My Health Insurance?
Doctors operate within a network of providers. If you choose a primary care physician that is out-of-network, you will end up paying more for your healthcare services. However, since all medical professionals are part of the Affordable Care Act, they are mandated to provide these 10 Essential Health benefits. They include:
• Outpatient healthcare
• Emergency services
• Pregnancy, maternity, and newborn care
• Mental health and substance abuse disorder services
• Prescription drugs
• Rehab and habilitative services
• Laboratory services
• Preventative and wellness services
• Pediatric, including oral and vision care
Does the Affordable Care Act affect who I can choose as my Primary Care Physician?
Some doctors and medical facilities can elect not to accept Affordable Care Act insurance. If you have a doctor that you normally see and you are shopping for health insurance in Austin or Dallas, it is best to talk with your doctor to see if they accept Obamacare insurance.
A Primary Care Physician can also differ depending on the type of plan network you have. HMOs tend to have more restrictions. You must select your Primary Care Physician and be treated by them for your initial visit; EPOs give you more freedom, you are allowed to go straight to a Specialist, and you don’t necessarily need to visit your PCP first for advanced medical care.
Whether it be your selecting a PCP or choosing a metal level, Cover Mile is available to assist you with understanding health insurance in Texas. We aim to guide you through the purchase process and how to select the best policy for you and your family. Contact us today.
Frequently Asked Questions
What is a primary care physician id number?
A Primary Care Physician ID number (PCP ID#) is a network identification number that works primarily with HMO plans. These directory numbers help identify the doctor or facility. It is also known as an NPI or National Provider Identifier. A PCP ID number is ten digits; an NPI number is nine numbers. In most cases, you can find a PCP ID# by searching for your Primary Care Physician’s name on your health insurance website.
What does it mean that a Primary Care Physician is affiliated with a certain hospital?
This is an agreement between a hospital and a PCP where the doctor has permission to use the hospital for their patients for tests and to admit their patients.