Direct Primary Care (DPC) is a healthcare model where patients pay a monthly or annual membership fee directly to their primary care provider. This fee covers most primary care services without insurance claims, such as routine check-ups, preventative care, and some minor procedures. It seems pretty straightforward. However, potential patients often want to know how to utilize their health insurance alongside DPC for other healthcare needs.

Using Health Insurance with DPC

While DPC practices don’t bill insurance for primary care services, patients can still use their insurance for services that fall outside the scope of DPC. Here’s how:

1. Specialist Visits: DPC covers primary care services and can often address needs that you may have historically consulted a specialist for (e.g. seeing ENT to get ears flushed…). But if you need to see a specialist (such as a cardiologist or dermatologist), your insurance can be used to cover these visits. There are DPC specialists; they just are not as common yet (especially not in my market).

2. Hospitalization and Emergency Care: If you require emergency care or hospitalization, your insurance can help cover those costs. This is an excellent use of insurance - providing financial protection for these high-cost services.

3. Prescription Medications: Many DPC practices (including ours) offer discounted prices on common medications, but for more expensive or specialized drugs, you can still use your insurance to cover the cost. This helps reduce out-of-pocket expenses for prescriptions that fall outside of primary offerings.

4. Diagnostic Tests and Imaging: Routine lab work may be included or offered at a significantly reduced price with your DPC membership, but for advanced diagnostics like MRIs, CT scans, or specialized tests, you can use your insurance to help cover these costs …. OR, if available, we can refer you to a CASH based imaging center.

Many DPC patients opt to combine their membership with a high-deductible health plan (HDHP). This type of insurance usually has lower premiums, and the DPC model handles the day-to-day care, helping to reduce out-of-pocket spending on smaller health issues. The HDHP can then be used for major medical events, hospitalizations, or specialized care.

While Direct Primary Care shifts much of your day-to-day care outside the traditional insurance model, health insurance remains useful for covering specialized care, emergencies, and high-cost treatments. DPC and insurance can complement each other, providing a well-rounded healthcare solution.