Patient Perspective: DPC & Insurance

Whether you're planning on opening a practice or have been in business a while, you'll have to have an idea of how DPC fits in with other health plans for patients. Knowing what options exist and directing people toward them will be a great benefit — and may help sell your membership even more.

Here's a quick rundown of how Direct Primary Care can work with or without insurance.

First: DPC isn't insurance

To be clear: Direct Primary Care isn't insurance. There's no transfer of risk, and the IRS and other government entities have already defined it this way.

DPC is a defined way of paying for health care — a certain set of procedures and services are provided for a flat monthly rate. As a DPC physician or clinic you aren't offering "coverage" and you don't "cover" anything. You include certain services and procedures as part of a membership. Coverage is for insurance, and DPC is not insurance.

However, DPC can be used as part of a health benefit package, whether it's paired with insurance, insurance alternatives, or nothing at all.

Here are the majority of options people have (the first and last are my favorite).

DPC alone

DPC membership alone is a viable option — especially for families that do not have any employer-sponsored health care options, are currently in transition, or simply can't afford it in the budget.

For everything outside of the DPC membership, they are considered cash-pay.

What if a catastrophic event happens? Here's where being cash-pay is actually more powerful than having insurance.

Why? Because so many programs exist to help ease the burden of medical bills for cash-pay patients.

This article isn't the place for explaining how that works or giving tips for those patients — but just know that I've seen people negotiate bills from over $250,000 down to less than $10,000, and then monthly payments are made on that amount for less than $200/month. That's less than an insurance premium payment!

DPC with Medicaid

Yes, some patients will join DPC even though they receive free or highly discounted state health insurance.

This option is pretty simple — just pair them together. With one caveat.

If their state-sponsored care is an HMO (Health Maintenance Organization) plan, or an EPO (Exclusive Provider Organization) plan, referring patients to specialists will likely be problematic. And by problematic, I mean nearly impossible — unless you live in a state like Maine where laws exist to force out-of-network primary care providers to be able to refer in-network.

So this option works best if they are in a PPO plan through the state. If not, then warn them that anytime a referral is needed, they'll have to go to their in-network primary care provider for that referral.

DPC with traditional insurance

DPC is most commonly paired with traditional insurance — and typically High Deductible Health Plans that may or may not be paired with a Health Savings Account.

Who should consider traditional insurance?

• Those that want the comfort of a traditional health plan and don't mind the slightly higher premium / monthly cost
• Those that may have a pre-existing condition where health sharing (explained below) may not work
• Tobacco users
• Those with chronic health conditions who are more at risk for high-cost health events

Tips:

• Consider a plan that includes a Health Savings Account (HSA), as DPC membership can now be paid out of those funds (see the article here)
• Warn against purchasing an HMO or EPO plan (as above in DPC with Medicaid) — referrals to specialists may not be possible. PPO plans are best.

As a provider, referrals are going to be hard with patients who have insurance. You'll learn what companies are best to work with, and can recommend those to future potential patients who might be looking for insurance options.

DPC with employer-sponsored insurance

Whether the employer is paying for employees, or an employee comes to you on their own, pairing DPC with their insurance works very similarly to DPC with traditional insurance above.

The same tips apply — including the HMO / EPO warnings and considering a plan with an HSA (often employers will contribute to that account!).

Some additional tips for patients with employer-sponsored health plans:

• Patients should consider all options for family members. Sometimes it makes financial sense to move family members to other plans (like health sharing) versus paying for them via the employer-sponsored plan.
• For patients who work for smaller employers but are paying for membership on their own — consider asking to talk with the owner about paying for DPC membership for all employees.

DPC with Medicare

If traditional insurance is confusing, Medicare is like quantum physics. It's very confusing.

DPC membership can be paired with Medicare. However, in order to charge a monthly membership fee to anyone that is Medicare eligible, the provider must be opted out of Medicare.

This is very important. If you are not opted out of Medicare and charge additional fees (like membership) outside of what Medicare allows, the government considers this Medicare fraud. And it's no joke.

Here's why and how to opt-out of Medicare.

My greatest advice for recommending plans to patients: work with a Medicare broker who understands how DPC works, who knows that you are an out-of-network provider for any plan they offer, and send all of your potential Medicare patients to them. Even better — have them write an article that you can give to potential Medicare patients to help them understand what they can look for in a Medicare plan.

DPC with health sharing / health ministries

This is my favorite option — pairing DPC with either a Health Sharing Organization / Company, or a Health Sharing Ministry.

How do they work? The premise is simple.

It's a community of people that come together for the purpose of sharing in one another's burdens — specifically medical needs.

It's not insurance. There's no transfer of risk. Everybody in the community is a cash-pay patient.

A health sharing ministry is a faith-based community, where usually some sort of "statement of faith" or other proof of being a faith-based person is required to be a part of that community. A health sharing organization is the non-faith-based version of that. Some health sharing ministries are recognized by the ACA and would exempt individuals and families from the health insurance mandate (if your state has a mandate).

They work really, really well because there aren't any middle-men or shareholders to please.

I have a few favorites that I've worked with in the past.

Health Sharing Organizations:

• Crowd Health (my current top recommendation)
• Sedera
• Zion Health

Health Sharing Ministries (all should be exempt from ACA mandates):

• MediShare
• Samaritan Ministries
• Christian Healthcare Ministries
• Liberty HealthShare

If you have questions or are looking for other input, consider joining the Skool community or get in touch with me!