Delegated and non-delegated medical groups

Delegated

The plan gives the medical group authority for some jobs the plan would otherwise do. Those jobs can include prior approval, referrals, credentialing, care coordination, and sometimes claims. You still have the plan’s appeal rights. “The group manages your care” does not remove the plan from the contract.

Not delegated

The medical group is a contracted provider. The Medicare Advantage plan keeps prior approval, referrals, claims, and care coordination. You follow that plan’s rules for those steps, not a separate group rulebook.

Who usually does the job

This is the usual split. A particular contract can differ. Ask before you rely on it.

• Prior approval: the group, if delegated. The plan, if not.
• Referrals: the group, if delegated. The plan, if not.
• Claims: sometimes the group, if delegated. The plan, if not.
• Care coordination: the group, if delegated. The plan, if not.

What people are told

People hear that a delegated group approves care faster, costs less, and coordinates chronic illness better, and that a group that is not delegated is the way into an academic hospital. Those are claims. They are not a promise about your copay, your wait, or your specialist. Ask who approves a referral on this contract, whether your specialists are in the group, and what the prior-approval step is.

Names in Los Angeles County

Often delegated: Optum and HealthCare Partners, Regal, Lakeside, Heritage, Prospect, Allied Pacific, Greater Covina, and Axminster. Facey is delegated on some UCLA contracts, not on every plan. Often not delegated: USC Care, Keck Medicine, Cedars-Sinai, Providence Medical Group, PIH Health, MemorialCare, Torrance Memorial, and City of Hope. UCLA is not delegated on most plans. Kaiser is the health plan, not a delegated IPA. A name with no label on the ZIP list was not in this set. The ZIP list shows which of these names have been observed near you. It is not proof your doctor is in the group.

Wanting a hospital is a separate question

Wanting USC, UCLA, Cedars-Sinai, or City of Hope means you ask whether that doctor, at that address, is in that plan this year. Being comfortable with Optum, Regal, Lakeside, or Allied Pacific is the same kind of question. Neither answer chooses a plan on this website. Write the names down with the questions for the front desk.