Insurance and Your DPC Membership: What You Need to Know

While primary care handles the vast majority of your medical needs, insurance is your safety net for the "big stuff." You still need coverage for:
• Specialist consultations
• Emergency room visits and hospitalizations
• Surgeries and complex procedures
• Advanced imaging (like MRIs or CT scans)
• Labs and Meds: You will still use your insurance at labs and pharmacies, and I can help find labs that are in network for you, as well as medications that are covered by your individual plan. Additionally, I offer some basic laboratory tests in the office at no cost to you. I may also be able to find laboratory tests for you at a cash price that could be lower than the typical insurance co-pay.
Pro-Tip: Some patients find they can save a significant amount of money by switching to a High Deductible Health Plan (HDHP) paired with a Health Savings Account (HSA). Since your day-to-day care is covered by your membership, you can often lower your monthly premiums and "break even" or even come out ahead—even after paying your membership fee. I recommend running the numbers with your insurance agent or HR representative to see which plan fits your lifestyle.

First you will want to know if your insurance is a Health Maintenance Organization (HMO), or a Preferred Provider Organization (PPO).
If you have a PPO, nothing really changes. You can see a specialist based on my recommendation just as you normally would, and I will facilitate this process directly. If you have an HMO (most Medicare Advantage plans are HMO), please be aware that they often require a referral from an in-network doctor. Since I am out-of-network, your HMO might not cover a specialist visit if I am the one referring you. It’s always best to check with your carrier if you’re on a restricted HMO plan.

If you need to go to the hospital, your care there will be covered by your insurance.
• Emergency Room: You’ll be treated by the ER staff on duty, but if I am aware, I will be able to give them advanced notice and provide them with helpful background, which only helps them provide more efficient care to you.
• Inpatient Care: You will likely be cared for by a "Hospitalist." While I won't have the authority to make final clinical decisions while you are admitted, I will stay in close contact with the hospital team to ensure your transition back to my care is seamless.

If you are a Medicare recipient, you can absolutely be a member of my DPC practice. However, because of federal regulations, we have to follow a specific set of ground rules to ensure you keep your benefits while enjoying the perks of direct care. Again, determine whether you are in an HMO plan, or a PPO plan (most Medicare Advantage plans are HMO).
1. The "Opt-Out" Rule
By law, a provider cannot bill both you (via a membership fee) and Medicare for the same primary care services. To offer a DPC model, I have "opted out" of Medicare.
• What this means for you: You will sign a simple one-page agreement stating
that neither you nor I will submit my office visit charges to Medicare for
reimbursement.

2. You Keep Your Medicare Benefits
Joining my practice does not mean you lose your Medicare coverage. Medicare remains your primary insurance for almost everything else. It will still cover:
• Specialists: If I refer you to a cardiologist or neurologist, your Medicare pays for
that visit just like always.
• Hospital & ER: Medicare Part A and B (or your Advantage plan) still cover
hospitalizations and emergencies.

• Labs and Imaging: Even though I order the tests, you can still go to a Medicare- approved facility (like a local hospital lab or Quest) and have those services billed

to Medicare.

• Prescriptions: Your Part D coverage remains exactly the same.

Many Medicare patients feel "rushed" in traditional offices that see 30+ patients a day.
In my practice, the relationship is the priority. You get:
• Longer Appointments: No more 10-minute "efficiency" visits. I take the time
needed to manage complex or chronic conditions.
• Direct Access: You can call or text me directly, which often prevents
unnecessary trips to the office, ER or Urgent Care.
• Advocacy: I act as your health "quarterback," helping you navigate the
confusing world of specialists and hospital systems.

As of January 1, 2026, federal rules have shifted to allow DPC fees to be considered "qualified medical expenses." If you have a health savings account (HSA) associated with a secondary plan, you can now use those tax-free funds to pay for your DPC membership (up to $150/month for individuals).

Still have questions about the math? I strongly encourage you to chat with your insurance broker to see how a DPC membership can fit into your financial picture. My goal is to make healthcare simpler, not more complicated!