Picture this – you are sold on the long-term health benefits offered by concierge medicine. You just have one concern left: how will my concierge medicine or direct primary care (DPC) subscription integrate with my existing insurance plan?
In this blog post, we settle the score between concierge medicine and insurance. Can these two live in harmony? What is the best method to incorporate both concierge medicine and insurance to achieve the best possible healthcare scenarios as a patient?
Concierge medicine is a type of healthcare model where patients pay a membership fee to receive personalized healthcare from a primary care physician (PCP).
This fee typically covers services such as routine check-ups, lab tests, and virtual visits. In exchange for the membership fee, patients receive:
The only downside is that concierge medicine patients without insurance are left unsupported and at risk in the event of emergency medical expenses.
The rule of thumb is concierge medicine covers routine, preventive care while your insurance provides coverage for in-patient costs, like hospitalizations, surgeries, and specialist treatments.
There are two ways you can complement your concierge medicine subscription with insurance: either with a high-deductible plan or with a healthshare or cost share plan.
High-deductible insurance plans have higher upfront costs compared to traditional insurance plans but they come with lower monthly premiums in the long term.
On the other hand, health share or cost share plans are an alternative healthcare arrangement wherein patients pool resources to share medical expenses.
These plans are often considered a more affordable option for individuals and families who cannot afford or do not want traditional health insurance.
How healthshare plans typically work is members pay a monthly fee to join, which is often lower than traditional health insurance premiums. Should a member of the plan incur any medical expenses, they submit a request for sharing to the healthshare plan.
The request is reviewed and determined whether it is eligible for sharing. If approved, the plan disburses funds from the collective pool to the member to help cover the medical expenses.
Read more about: Concierge Medicine as a Patient-Centered Care Model
One of the biggest misconceptions about concierge medicine is that it replaces traditional insurance coverage. However, this is not the case. Concierge medicine is designed to work in conjunction with your existing insurance coverage.
Here are a few ways concierge medicine and insurance can work together:
Hybrid Model: Some concierge medicine practices offer a hybrid model, where patients pay a membership fee for personalized preventive care. This means concierge membership fees are paid on top of insurance premiums.
On the other hand, their insurance coverage is used for specialist referrals, hospitalizations, and other services not covered by the membership fee.
In this model, both concierge medicine and insurance coexist in harmony. In fact, they even complement each other to give patients the best possible health scenarios.
Wrap-around Insurance: Some insurance companies offer wrap-around insurance policies that cover services not included in the concierge medicine subscription.
These policies typically have lower premiums and higher deductibles.
Recent developments regarding regulatory clarity within concierge medicine and insurance have emerged. Last November 2024, H.R. 3836, or the Medicaid Primary Care Improvement Act, was passed.
The bill clarifies that Medicaid programs can now offer direct primary care (DPC) services without patients needing to secure a federal waiver from the Centers for Medicare & Medicaid Services (CMS).
H.R. 3836 is a major step towards simplifying direct primary care (DPC) and insurance for Medicaid patients. The bill has eliminated a huge chunk of the complicated, lengthy process in having access to quality preventive care in DPC.
Regulatory-leading bodies such as the DPC Coalition and Health Rosetta are also leading the charge in shaping policy, integrating technology, and driving integration of concierge models in the public healthcare landscape.
Direct Billing: Some concierge medicine practices bill insurance companies directly for services rendered, eliminating the need for patients to file claims.
Upon subscription, a concierge medicine practice will usually request for your insurance details so that they can manage insurance claims on your behalf.
As per current IRS regulations, most medical services accrued within a concierge medicine subscription are now eligible for reimbursement.
Most insurance companies now cover laboratory examinations, co-pays, prescriptions, and other medical expenses. As for non-covered services, these are considered out-of-pocket expenses handled by the patient.
As for HSA or FSA accounts in concierge medicine, it is still unclear which medical expenses are eligible for reimbursement. One thing is for certain: you cannot use HSA/FSA funds to cover monthly concierge membership fees.
For further clarity on reimbursements, make sure to check with your HSA/FSA administrators which expenses are eligible for coverage.
The answer is a resounding yes. Combining concierge medicine and insurance offers numerous other benefits, including:
Personalized care: Concierge medicine provides direct access to primary care physicians, ensuring patients receive personalized care and attention.
Comprehensive coverage: Insurance coverage ensures patients are protected against unexpected medical expenses, such as hospitalizations or specialist referrals.
Cost savings: While paying for both concierge medicine and insurance may seem counterproductive in terms of managing medical budgets, the reality may surprise you.
These days, the average cost of premiums, copays, and deductibles in traditional insurance plans come up to $10,000 to $15,000 a year. .
This comes out more expensive compared to $1500 a year for a direct primary care (DPC) membership plus $5,000 a year for a bare-bone premium in catastrophic insurance.
Moreover, monthly premiums for traditional health insurance can vary wildly, from $393 to $1,843, depending on whether you're covering just yourself or your entire family.
And that's not all - you'll also be on the hook for out-of-pocket expenses like deductibles, copays, and coinsurance, which can add up to an additional $2,000 to $5,000 or more per year.
Now, compare that to direct primary care (DPC) memberships, which usually cost between $50 to $150 per month for individuals and $100 to $450 for families.
Even when paired with catastrophic coverage, which can run an extra $150 to $550 per month, the total cost of DPC is still much lower than traditional insurance.
Improved health outcomes: Concierge medicine's focus on preventive care and wellness programs can lead to improved health outcomes and reduced healthcare costs.
Case in point, a Harvard study spearheaded by the Group Health Cooperative in Seattle, Washington reveals a 29% drop in ER visits for patients in concierge medicine settings.
Improved outcomes are also evident in chronic care patients who are diagnosed with heart disease and diabetes.
When choosing a concierge medicine practice and insurance combination, consider the following tips:
Healthshare, non-insurance companies, like Sedera Health and Zion Healthshare, are well-versed in helping patients come up with the best health strategies.
They offer patients sound advice as to how to best combine concierge medicine and insurance, as well as how to manage healthcare costs.
