A Primary Care Physician (PCP)
by Karen Kehr, MS
Benefits Manager, American General Financial Corporation
An Employee Benefits Annual Enrollment
You are sighing relief and the big decision
has been made. The dreaded medical plan option, which
good or bad, you are stuck with it until next year. Well,
you still have some important follow-up items:
Select A Doctor
If you enrolled in a Health Maintenance Organization
(HMO) or a Point of Service (POS), you are required to
select a primary care physician. You must communicate your
selection to your carrier. If you are enrolled in a Preferred
Provider Organization (PPO) plan, you are not required
to select a primary care physician. However, those enrolled
in a PPO would be wise to review the provider directory
for doctors to use when in medical need. Non-use of selected
providers may result in reduced benefits (PPO, POS) or
no benefits (HMO).
The doctors in the networks are required to meet
standards (credentials) set by the carrier. These credentials
do vary by carrier. You can be assured that all carriers
verify medical schooling and licensure. Some carriers require
board certification. Board certification is an additional
certification in the field in which the doctor practices.
The carrier should be able to provide you this information
through member services if it is not indicated in the directory
or you may want to contact the doctor's office.
Things To Consider
Other facts to consider in selecting a doctor include;
doctor office location and hours, hospital affiliation,
bedside manner, years of experience, schooling and side
specialties. It might be more convenient to access a doctor
close to work or day care than home. Perhaps, it is difficult
to leave work so weekend or evening hours may be most convenient.
Access to a particular hospital may be important. For example,
Houstonians with children would most likely want access
to Texas Children's Hospital in the medical center. Or
maybe the thought of driving and parking in the medical
center sends chills down your spine, so access to a hospital
close to home is most important.
Unlike your medical plan option, you may change
your primary care physician. So while the decision is important
for access to care, if you have a less than desirable experience,
you may change PCPs up to once a month with an HMO and
anytime with a POS.
Review Benefit Changes
Benefit plans do change and you need to be educated
on the changes to properly access services. Employers provide
written communications of plan changes either in a flyer
or brochure. In addition, employers provide summary plan
descriptions (SPDs). For example, my company changed to
a co-payment drug plan in which certain drugstores must
be accessed for services. Some employees overlooked this
change and continued as if they could use any drugstore.
Needless to say, when they submitted their claims and they
were denied, these were not happy campers.
Update Your Life Insurance Beneficiary
As a benefits manager, I have experienced some
heart breaking situations when beneficiaries have not been
updated. If you don't have a copy of your current life
insurance beneficiary designations, ask your human resources
department for one. Or if your coverage is not with an
employer, check with your personal carrier. I have seen
ex-spouses as the designee leaving the current spouse with
nothing but the funeral bill.
Changes During the Year
Life events during the year such as a birth, marriage
or divorce entitles you to make changes to your benefits
options as long as you report the life change within 30
days (some employers allow up to 60 days) of the event.
If you do not do it in the time frame required then you
will have your current benefit selections until next year.
The reason for the time requirement is internal revenue
code 125, which allows benefits deductions on a pre-tax
Be a smart consumer!
Employers provide some excellent benefits but it
is up to you to use them wisely.