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FAQs and Answers Related To DPC, Insurance Considerations, HSAs, The Affordable Care Act (Obamacare)

FAQs and Answers Related To DPC, Insurance Considerations, HSAs, The Affordable Care Act (Obamacare), HDHPs and more.

RELATED: BUSINESS MODELS: A Simple Look at the Best Corporate Structure for Your DPC Practice

Is Direct Primary Care (DPC) Health Insurance?

Answer: No. DPC doctors work directly with their patients to provide primary and preventive care services that are usually described to patients in our a short summary Agreement/Contract or Patient Services Guide. DPC doctors and DPC offices do not provide specialist, hospital or emergency care, but can refer patients to providers within a desired network.

RELATED: Legal Section: ‘Are Direct Practices Insurance?’ ~John R. Marquis, WNJ

Most DPC doctors/offices (not all, approximately 30%+ do participate in insurance) do not bill any insurance carrier for their services. DPC doctors/office usually offer monthly care fees which are not reimbursable by any health insurance company, and may not be applied to any insurance plan deductible. Your insurance plan may be billed by others for services such as emergency, hospital, specialty care, laboratory tests, diagnostic imaging, prescription drugs or other goods and services that are ordered by your DPC doctor/office health care provider but are not performed or provided in their offices. Ask your DPC doctor/office about how their practice works with insurance.

RELATED: Typical Services Inside A DPC Office

Do You Have To Have Insurance To Use Direct Primary Care (DPC)?

No. But it’s important to understand that almost all DPC doctors/offices advise patients to have some form of insurance in the event of catastrophic event or illness. Anyone can become a DPC patient at anytime. Typically, DPC doctors/offices do not pre-screen or deny patients because of their age, race, religion, national origin, health condition including the presence of any sensory, mental, or physical disability, sexual orientation, education, economic status, employment status or citizenship.

RELATED: How does Direct Primary Care (DPC) work with High Deductible Health Plans (HDHP) and HSAs?

Are There Long-Term Contract Obligations?

No. Most DPC doctors/offices offer services which are paid for on a month-to-month basis and patients can cancel at anytime.

Download Entire White Paper of FAQs In The DPC Journal BookStore — Free, of Course — CLICK HERE

The Affordable Care Act (Obamacare)

  • When you read the language of the law, it does not state that there is a requirement that the DPC doctor take insurance or report to entities to fit the model. The law does define a Primary Care Provider: ‘‘(B) PRIMARY CARE PROVIDER.—The term ‘primary care provider’ means a clinician who provides integrated, accessible health care services and who is accountable for addressing a large majority of personal health care needs, including providing preventive and health promotion services for men, women, and children of all ages, developing a sustained partnership with patients, and practicing in the context of family and community, as recognized by a State licensing or regulatory authority.

  • In the back of the law there is amendment 10104 that clearly says a qualified medical plan can use Direct Primary Care as a part of the plan: ‘‘(3) TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME PLANS.—The Secretary of Health and Human Service shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.

  • The DPC Journal has learned from its industry sources that found within the law for a medical home, it does not say insurance payment – it simply says payment. Additionally, (2) support patient-centered medical homes, defined as a mode of care that includes— (A) personal physicians; (B) whole person orientation; (C) coordinated and integrated care; (D) safe and high-quality care through evidence informed medicine, appropriate use of health information technology, and continuous quality improvements; (E) expanded access to care; and (F) payment that recognizes added value from additional components of patient-centered care.

  • RELATED: The Affordable Care Act and HSAs

  • Additionaly, The DPC Journal has learned that in Section 5000 (A) it defines a qualified plan as a plan the meets “essential coverage” and further defines essential coverage in either the individual or group markets as: ‘‘(f) MINIMUM ESSENTIAL COVERAGE.—For purposes of this section— ‘‘(1) IN GENERAL.—The term ‘minimum essential coverage’ means any of the following: ‘‘(C) PLANS IN THE INDIVIDUAL MARKET.—Coverage under a health plan offered in the individual market within a State.‘‘(2) ELIGIBLE EMPLOYER-SPONSORED PLAN.—‘‘(B) any other plan or coverage offered in the small or large group market within a State.As The DPC Journal writes this and our sources interpret and read this, the actual wording indicates if a plan is approved for sale in a state the requirements are met. The insurance department in each state approves what can be sold in that state, so if the department approves a plan for sale, it can be sold.

  • What about specific plans? That was easy prior to 1/1/2014, sources tell The DPC Journal. Since then insurance companies have been intimidated to capitulate to HHS, when in fact, there is NO PENALTY to an insurance company for offering what ever plan they want to make available for sale.Unfortunately as well is that many companies have withdrawn from the individual market – even outside of the exchanges – due to a section of the law that says if other companies lose money selling in the exchanges, those that do make a profit – in or outside of the exchange) must SHARE up to 80% of that profit with the losers. So, at this point in time (June 2014) only a few small and localized employers/companies, are designing custom plans to carve out the DPC on the individual market.

  • “I checked with my very literate insurance agent about the catastrophic policy plus DPC membership. This is very important for your [The DPC Journal] readers and patients to know — if these catastrophic plans are offered, they do not meet ACA Minimum requirements for coverage, so policy holders with “only” this coverage would be in violation of the law and subject to fines, as if they had no insurance…..unless we get the law changed. For a single policy holder, this could be as little as $95 or as much as 1% of the amount by which your income exceeds the sum of a single person’s personal exemption and standard deduction in the federal income tax FOR EACH FAMILY MEMBER not insured. Not sure how much that could be , but it could be thousands for high income earners.” ~Dr. C., Atlanta, GA, April 2014

  • The only choice individually is the HSA qualified HDHP, report health insurance sources and DPC physician tell The DPC Journal. It does give the ability to pre-tax save money to pay the smaller medical expenses. The problem with most of the lower premium plans is really high deductibles – like locally Coventry offers a $6300 per person deductible at the lowest rate. (still 5 times higher than in 2013), says one health insurance industry expert in a The DPC Journal interview. At present, there are a wide variety of choices on group, including one company now going down to a 2 person ERISA (self insured) plan.

HSA Education: “Top 5 Things You Should Tell Your Patients About HSAs”

RELATED: HSA Education: “Top 5 Things You Should Tell Your Patients About HSAs”

By Roy Ramthun, HSA Consulting Services, CMT Contributor

  • Be smart about your health insurance. Instead of paying thousands of dollars for health insurance you may never use, switch to an HSA-qualified insurance policy that covers larger medical bills and use the premiums savings to fund a Health Savings Account (HSA). If you “pay yourself,” you get to keep the money you don’t spend.

  • HSAs provide true catastrophic insurance protection. Annual limits on out-of-pocket expenses (e.g., deductibles, copays, coinsurance) apply to all benefits covered by your plan (including prescription drugs). These limits cannot be higher than $6,350 for self-only coverage or $12,700 for family coverage in 2014 (adjusted annually for inflation).

  • HSAs put you in charge of your medical care. Having funds in an HSA allows you the flexibility to pay for medical care not covered by your insurance, including benefit exclusions, second opinions, out-of-network treatments, and over-the-counter products. Choose the care that you and your doctor believe is best for you.

  • HSAs save you money on taxes. Every dollar you put in your HSA is deductible on your income tax return, up to the annual limits ($3,300 for singles and $6,550 for families in 2014). These limits are adjusted annually for inflation. Individuals age 55 or older can make an additional $1,000 contribution each year until they enroll in Medicare.

  • HSAs can be invested and saved for medical expenses in retirement. HSA funds can be invested just like an IRA. Growing your account through investment earnings can help expand your nest egg for retirement. HSA funds can be saved and used to pay for Medicare premiums and out-of-pocket expenses as well as long-term care expenses and insurance premiums.

RELATED: HSA SERIES, PART 1: Frequently Asked Questions About HSAs


Roy Ramthun, “Mr. HSA” HSA Consulting Services, LLC 202-747-4467

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