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Medicare FAQ's

Direct Primary Care (DPC) and Medicare or Medicare Advantage plans

Direct Primary Care (DPC) is a healthcare model where patients pay a membership fee directly to their primary care physician for a defined set of services, rather than through insurance. This membership fee typically covers routine checkups, sick visits, chronic disease management, and other primary care services. 

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Medicare Advantage (also known as Medicare Part C) is a type of health insurance plan offered by private companies that contract with Medicare to provide you with all your Original Medicare Part A and Part B benefits. 

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How DPC and Medicare Advantage can work together:
 

  • You CAN still have a Medicare or Medicare Advantage plan and use a DPC practice.
    You simply cannot use your Medicare or Medicare Advantage plan to pay the DPC membership fee.
    You'll pay the DPC fee directly out-of-pocket.

    • (Imagine a fee that allows a doctor to actually call you back to answer questions, AND you can get seen in a timely manner)
       

  • Your Medicare or Medicare Advantage plan can still be used for services not covered by your DPC membership, such as:
     

    • Specialist visits: Your Medicare or Medicare Advantage plan will cover visits to specialists as it would if you weren't using DPC.
       

    • Hospitalizations and Emergency care: These services are typically not covered by DPC memberships and will be covered by your Medicare or Medicare Advantage plan.
       

    • Lab work, imaging, and procedures: While some DPC practices may offer basic in-house lab work (at Core Health, we've contracted for highly discounted labs through Quest), your Medicare or Medicare Advantage plan will cover most lab tests if you prefer to run it through insurance, x-rays, and procedures ordered by your DPC physician at Core Health.
       

    • Prescriptions: DPC memberships in Arkansas typically do not cover prescription drugs due to state pharmacy laws.

      • You'll need a Medicare Part D plan or a Medicare Advantage plan that includes prescription drug coverage to cover these costs. 
         

Benefits of using a DPC practice with Medicare (or Medicare Advantage):
 

  • Enhanced Access to Primary Care:

    • You'll likely have shorter wait times and longer appointments with your DPC physician, allowing for more personalized care.
       

  • Improved Doctor-Patient Relationship:

    • DPC practices typically have smaller patient panels, allowing physicians to spend more time with each patient and build stronger relationships.
       

  • Cost Savings on Primary Care:

    • DPC can be more cost-effective for routine primary care services, as the membership fee covers most services without additional copays or deductibles.
       

  • Focus on Preventive Care:

    • DPC prioritizes preventive care, which can help you stay healthier and avoid costly health problems down the road.
       

  • Reduced Administrative Hassles:

    • DPC practices typically don't bill insurance companies, simplifying the billing process and reducing paperwork for both you and your physician. 
       

Considerations:

  • You'll be paying a monthly fee for your DPC membership in addition to your Medicare Advantage premiums.

    • Recall: a fee that allows a doctor to actually call you back to answer questions, AND you can get seen in a timely manner.
       

  • DPC practices may not be suitable for everyone.
     

  • DPC practices do not cover major medical events like hospitalizations or emergency services, so you'll need your Medicare Advantage plan for those. 
     

Using a DPC practice alongside a Medicare or Medicare Advantage plan can be a good option for people who value a close relationship with their primary care physician and want more personalized care. However, it's important to understand the costs and benefits of both options before making a decision. 

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