Receiving Care from an Accountable Care Organization
An Accountable Care Organization (ACO) is a group of doctors or hospitals who have agreed to work together to coordinate and improve their patients’ care. Coordinating care means that all of the people treating you know your medical history and treatment plan. In some cases, all of your medical information will be stored in a personal electronic health record. You, your doctors and other providers can share that record. That way, everyone has a full picture of your health. That helps you avoid getting the same screenings or tests twice. It also makes sure you get preventive care like flu shots or, if you have diabetes, regular blood tests.
An ACO is not a type of health plan. It is just a way of organizing your care within the plan you already have. Your doctor or insurer may invite you to join an ACO. You also may ask your plan whether you are already in an ACO, and if you are not, whether you can join one. There should be no extra cost for using an ACO. You may even get rewards for meeting certain “good health” guidelines.
In an ACO, doctors and hospitals are paid more if they meet specific quality goals. The goals may involve preventive care and taking care of patients with long-term health issues like diabetes or heart disease. Patients in an ACO may be able to visit providers outside the organization for care. But, if you are in a private plan, there may be higher costs for going outside this “network within a network.” If you are in a Medicare ACO, you can still see any doctor who accepts Medicare without paying more.
If you are in an ACO:
- Talk to your primary care physician (PCP) about your care and understand who is in your ACO network.
- Ask your plan if you will pay more to visit doctors outside the ACO, even if they are in your plan’s broader network.
An Accountable Care Organization, or ACO, is a group of doctors, or a group of hospitals, who have agreed to work together to coordinate and improve their patients’ care. Their shared goal is to improve the quality of care, keep patients healthier and reduce unnecessary services. If you receive care through an ACO, the provider who coordinates your care—often, this is your primary care physician—will work with other providers and specialists to make sure you are getting the preventive care and regular treatment that you need. This means that you shouldn’t get the same test twice, or have services you don’t need.
An ACO is not a type of health plan. It is just a way of organizing your care within the plan you already have. Keep in mind that there are many different types of ACOs. Medicare has been testing ACOs for a few years, and many private insurers are developing their own ACOs. Your doctor or insurer may reach out to you about joining an ACO that they have started. You also may ask whether you are in an ACO, and if you are not, whether there is an option that you can join.
Can I see doctors outside the ACO?
It depends. Think of an ACO like a “network within a network.” Based on the program, patients in an ACO may be able to visit providers outside the organization for care. For example, if you are in a Medicare ACO, you can still see any doctor that accepts Medicare without paying more. If you are in an ACO through a private health plan, you may also be able to see other doctors in your plan’s network. But, if you see providers outside the ACO—even if they are in your plan’s larger network—you may have higher costs. You may also have higher costs if you go to a doctor who is outside both the ACO and your plan’s larger network. Be sure to check with your plan about coverage for out-of-ACO and out-of-network care first.
Your Action Plan: Be Informed
- Ask questions! If you are not sure whether you are in an ACO, ask your doctor or insurer.
- If you are receiving care from an ACO, make sure you understand whether you can see providers outside of the ACO, and your coverage for out-of-ACO and out-of-network care.
- If you are not receiving care from an ACO, but would like to—for example, if you have a chronic condition—ask your insurer or doctor whether there are ACO options open to you.
Remember, you are your own best advocate! Ask questions if there is something you do not understand.