Can I use my insurance with Direct Primary Care?

There's still quite a bit of confusion about Direct Primary Care and how it interacts with any medical insurance you may have.  Many potential patients now recognize that Direct Primary Care (DPC) gives unmatched access to your physician at a lower cost than insurance based practices, but having an out of network DPC physician still raises a lot of questions for patients.

We accept patients with any insurance except (temporarily) Medicare.   We accept Mainecare (Medicaid) patients .   We're eagerly planning to include Medicare patients but Medicare's regulations are quite punitive towards physicians looking to innovate so this may not change until later this year. 

We don't submit bills to any insurers, but most insurances will reimburse you for a good portion of your Direct Primary Care.   If you wish to pursue this, we can provide you with two complete office notes suitable for submitting to your insurer.  After 13 years of working for insurance payments, I know how to write office notes to meet their complex rules.  If this works well for you, additional visit notes suitable for submitting to insurers are available for a small fee. 

More importantly, most insurers will cover prescriptions, tests or referrals I order.   More accurately, they put up the usual prior authorization roadblocks, but this is no worse nor complicated than it is for an insurance based primary care physician.  The exception to this is that some HMOs may require a network primary care provider (PCP) to approve these.  So far we've only encountered one HMO like this in midcoast Maine.

We've already had several episodes where an insured patient found that the significant cash discounts we found on testing or medications were so much below the "discounted" price negotiated by their insurance, that they opted to not use their insurance.  Whether this makes sense for a patient usually depends on whether they expect to hit their deductible that year.

We also welcome patients who are uninsured.   We recommend, but don't require, that you carry at least a high deductible policy.  While we can save you quite a bit on primary care and non-urgent testing, medications and referrals, sometimes you may need an urgent test at the hospital or an emergency room visit.  That's when you need insurance to protect you financially.

For those of you with a low deductible and low copay insurance policy, enjoy that while it lasts.   The ACA's Cadillac Tax kicks in shortly and will hit employers who offer these policies with a penalty.   Many of us are already on relatively high deductible and high copay plans similar to the bronze plans offered on the insurance exchanges.  For those patients, DPC works very well to reduce your out of pocket costs.