What is the primary care physician rule?

The Primary Care Physician (PCP) Rule is an important part of California’s health insurance law. This rule states that a health plan must provide enrollees with access to a primary care physician (PCP). In order to be considered a PCP, the physician must be either a doctor of medicine (M.D.), doctor of osteopathic medicine (D.O.), doctor of podiatry (D.P.), doctor of optometry (D.O.), or a nurse practitioner (NP). The PCP must also have an active and unrestricted license to practice in California. The purpose of the PCP Rule is to ensure that enrollees have access to a medical professional that can provide a broad range of primary medical care services. This includes the diagnosis and treatment of illnesses, injuries, health conditions, preventive services, and health promotion. The PCP must be able to refer patients to specialists when needed, act as a patient advocate, and coordinate the enrollee’s care. The PCP should also be willing to discuss any health concerns the enrollee has, refer the enrollee for further tests or evaluation if needed, and answer any questions the enrollee might have. The PCP Rule ensures that all enrollees in California are able to access a medical professional to provide basic primary care services. It is important that enrollees take advantage of the services and advice their PCP provides in order to stay healthy and catch any health issues early.

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