Direct Primary Care and Your Insurance: What You Need to Know

First Track Primary Care- Now Enrolling in South Kingstown, Rhode Island

A common question I get is: “I pay a lot for insurance. You want me to pay more to not use it?” The short answer is yes. If I do my job well, you should use your health insurance more efficiently, and save money in the long run. My Direct Primary Care (DPC) model covers your primary, outpatient care, but it isn't a replacement for comprehensive insurance. Here is how the two work together to protect both your health and your wallet.

As of 1/1/26 DPC membership is now a qualified medical expense for

Health Savings Accounts (HSA’s)

Why You Should Keep Your Coverage

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.

Seeing Specialists

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.

What Happens if I’m Hospitalized?

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.

Medicare & DPC: How They Work Together

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 Medicareapproved

facility (like a local hospital lab or Quest) and have those services billed

to Medicare.

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

3. Why Bother with DPC if You Have Medicare?

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.

4. New for 2026: HSA Changes

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. Mygoal is to make healthcare simpler, not more complicated!

Schedule a complimentary meet & greet or give me a call and we can talk through this more to discuss your individual needs.