Page 23 - Commercial Group Member Guidebook

Straight Talk

Participating practitioner and provider facility networks can change
HMOs maintain networks of participating practitioners and provider facilities that you must use to
get your care covered. But those networks can change at any time. Sometimes doctors can leave
after you have enrolled in a plan, so you might have to switch your doctor to get your care covered.
In those cases, we always make sure there are enough alternative doctors available to provide your
care, and we have extensive transition-of-care programs to ensure that your transition to a new
doctor goes as smooth as possible.

In POS Plans, you can use non-participating practitioners

In Point-of-Service (POS) plans, you have the option of using non-participating practitioners and still
getting your care covered. That’s one reason people enroll in POS plans — so they will have the
option of using a doctor that’s not in the plan’s participating practitioner network. But that care will
always be paid at the lower level of benefits. If you want the higher level of benefits, you have to use
a participating practitioner.

Health care practitioners are motivated to think about the care
they give
Many participating practitioners and provider facilities in HMOs accept “financial risk” for treating
members. This means the amount of money the practitioner group receives from the managed care
company depends on how many services the group performs. If they perform more services than
expected, their compensation may be less. And, if their group provides fewer services than they
expected to, then they may get paid more. However, no individual doctor’s pay is directly related to
any particular care he or she does or does not give, and each doctor is always expected to act in the
best interest of each of his or her patients.

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