Health Maintenance Organizations (HMO) and Health Maintenance Organization Point-of-Sale (HMO-POS) plans often require plan members to choose a primary care physician. That physician must be one of the in-network participating providers who are contracted to work within the plan’s network of healthcare providers. Sometimes this requirement can be challenging when the client’s current primary care physician is not in the network of the best available HMO plan. At other times, this requirement is tricky because not everyone has a primary care physician.
When you fill out an enrollment application for these Medicare Advantage plans, there will be a place on the form to list a primary care physician. If the client leaves this blank, the plan will automatically assign a primary care physician.
Carriers track how many members are auto-assigned to a primary care physician because plan members with an auto-assigned primary care physician are more likely to be dissatisfied with the plan. As an agent, you should avoid these PCP auto-assignments so your carriers see that your sales process is fully compliant.
Ways to Avoid PCP Auto-Assignment
Finding the plan that is best suited to the needs of your client is your priority in the sales process. You may find that this recommended plan requires Medicare beneficiaries to choose a primary care physician within the plan’s network. Ask your client who their current providers are, and check their names against the plan’s provider directory. Looking at the plan’s online directory will give you the best chance of finding up-to-date information, compared to checking the physician office website or a general web search.
For providers that your client is already affiliated with, you can take down the physician’s name and number exactly as it is listed in the plan’s provider directory. Make sure that the client’s preferred provider or facility is in-network for the plan, because that in-network status affects the coverage and costs when your client visits the physician. If their preferred physician is out-of-network, you may ask the client what types of doctors and facilities are important to them, including specialists they only see occasionally. Look up all physicians and facilities to help them find one that’s in-network. The client is free to switch at any time, so encourage them to choose one.
Once the client has chosen an in-network primary care physician, you can use the physician’s name and number as listed in the plan’s provider directory and list this where required on the enrollment form.
