Medicare University Powered By Local Medicare Agents

Medicare University Enroll With Confidence

What are Medical Groups?

impressed looking at side young female doctor wearing medical robe with stethoscope grabbed chin isolated on yellow background

If you have been on an HMO insurance plan, you may have heard the term medical group. Medical groups are arguably the most important aspect of your HMO insurance, but like most you may be unaware of who they are. 

Important Note: Medical groups are also referred to as an IPA. This stands for Independent Physicians Association. They operate in the exact same capacity for your care. For now, just know that the difference in name is administrative and will not affect any difference in care or quality of experience for your plan. 

What is a Medical Group?

Health plans contract with local groups of doctors to provide your healthcare. These groups of doctors are called medical groups or (MG). While a small number of health plans – fewer than twenty – insure most people in California, there are hundreds within the state. This is because the needs and relationships for local patients isn’t something that can be easily stamped out in a cookie cutter fashion. Each county can vary greatly from one another in terms of number of doctors, average medical cost for services, patient education needs, and more. Hence, medical groups are created on the local level to ensure the needs of both the patients and the doctors are provided for. 

The difference between a MG and a health plan sometimes isn’t always clear for the patient. The medical group’s job is to care for patients – this work is done by the doctors, nurses, therapists and other professionals. The health plan is responsible for seeing that its members can access care easily by contracting with enough medical groups in a local area so it is convenient for members to get care nearby. The health plan pays for the care as well and typically determines what services and the amount that will be covered. This relationship can be best explained in the picture below. 

The job of a health plan and its contracted medical groups can vary depending upon the type of health plan. In a PPO plan, the doctors’ and medical groups’ main responsibility is to care for patients. In an HMO plan, the doctors and medical group often have a bigger job – in addition to providing patient care, the medical group is responsible for the patient’s overall health – including steps to avoid future health problems. The medical group and its doctors’ care and service for HMO members is explained below.

Why Are Medical Groups Important to Me?

Senior looking at health paperwork.

There are two main reasons why medical groups are important to you, as an HMO member. 

First, it is usually the medical group or one of its doctors, not the HMO health plan, that decides what care you receive and how you receive it. For example, the medical group:

  • Check that doctors are providing the type of preventative care approved by Medicare.
  • Sets the rules for you to receive a referral to see specialists and get other care.
  • Decides the steps doctors must follow when diagnosing and treating health problems.
  • Validates the training and experience of new doctors.
  • Decides where you go for hospital care and other medical services.

Second, one doctor cannot take care of every medical problem that you may have. The doctors in a medical group work together to make sure that you get all the care you need. These doctors include your primary care doctor and other doctors known as specialists.

Important Note! Because the MG determines who you can see, it’s important that you ensure all your doctors accept the same Medical Group. To find out if they do, you may either call each doctor or work with a broker who will research this for you. If you happen to choose a MG that your doctors don’t accept, then you will not be covered by your Health Plan when you see them. Interestingly, each Medical Group only works with certain Health Plans. Because of these selective partnerships, there are Health Plans with great benefits that may not be available to you because they unfortunately do not contract with your doctor’s MG. 

Senior couple using a digital device in a living room reading up on "What are Medical Groups."

The good news is that you have access to great benefits with reasonable rules. The responsibility is often up to you to ensure you are able to maintain your continuity of care (meaning to continue all current doctors and services). Medicare has rules stating that each broker should ensure this continuity of care doesn’t get interrupted, but many will have stories that say otherwise. For this reason, setting up a Medicare Advantage Plan that will best fit your individual needs is of utmost importance, and further, finding someone trustworthy to help you through the decision making process even more so. Once your Health Plan and MG are set up properly, the plan will take care of itself…and you. 

Contact Us
[wpseo_address id=”2675″ hide_name=”false” hide_address=”false” oneline=”false” show_state=”true” show_country=”false” show_phone=”true” show_phone_2=”true” show_fax=”true” show_email=”true” show_url=”false” show_vat=”false” show_tax=”false” show_coc=”false” show_price_range=”false” show_logo=”false” show_opening_hours=”false” hide_closed=”false”]
[wpseo_address id=”2968″ hide_name=”false” hide_address=”false” oneline=”false” show_state=”true” show_country=”false” show_phone=”true” show_phone_2=”true” show_fax=”true” show_email=”true” show_url=”false” show_vat=”false” show_tax=”false” show_coc=”false” show_price_range=”false” show_logo=”false” show_opening_hours=”false” hide_closed=”false”]
[wpseo_address id=”3353″ hide_name=”false” hide_address=”false” oneline=”false” show_state=”true” show_country=”false” show_phone=”true” show_phone_2=”true” show_fax=”true” show_email=”true” show_url=”false” show_vat=”false” show_tax=”false” show_coc=”false” show_price_range=”false” show_logo=”false” show_opening_hours=”false” hide_closed=”false”]


Skip to content