Cheat Sheet for Making Direct Primary Care Work With Medicare
With over 10,000 baby boomers turning 65 and many retiring each year, we often overlook the fact that a good portion of those boomers are also physicians. Recently, we’re seeing countless patients scrambling to find new primary care doctors or new Medicare plans due to their doctor retiring or electing a Direct Primary Care practice (DPC) .
DPC has been on a steady increase due to the concierge level of care at a reasonable monthly price. It’s a win-win that allows physicians to practice without the layers of bureaucracy and patients the 24/7 access to their doctor.
Although DPC gives great access and convenience, many individuals on Medicare are finding that some insurance plans may not be as friendly towards DPC practices. DPC practices typically do not participate in any insurance program and are not able to make referrals. To make sure that you’re selecting the right Medicare plans to complement your DPC doctor, here’s a quick crash course on Medicare and what to look for:
What is Medicare?
Medicare is health insurance for individuals 65/+, disabled for 24 months, or with certain conditions. There is an alphabet soup that’ll drive you nuts. Part A covers hospitalization and Part B covers outpatient services. For most individuals that have paid 40 quarters into the Medicare system via payroll taxes, Part A is $0. Part B is $174.70/month (2024) and can be higher based on your income.
There is a $1,600 (2024) deductible for Part A and a $240 deductible + 20% co-insurance for Part B (meaning you’re on the hook for 20% of whatever costs come up).
Medigap Coverage
To fill in the gaps, some individuals select a Medigap (or a traditional Supplemental Plan) along with a stand alone drug plan (Part D). Some of the most common supplemental plans include Plan C, F, G, N. (we won’t go into details here for sake of sanity). The benefit of choosing a Medigap plan is their flexibility in providers as well as protection against big costs such as hospitalization and outpatient surgeries. The downside is typically the monthly price.
Key point: Medigap plans work well with DPC practices because they supplement Medicare Parts A/B. You can go to any doctor/hospital that takes Medicare with no referrals. Although Medigap plans do not cover the cost your DPC doctor, your DPC doctor will still be able to coordinate your care and recommend services without the need for referrals.
Medicare Advantage Plans
Medicare Advantage plans (or Part C) is essentially privatized Medicare. Advantage plans are structured where a private insurance company (Such as Blue Cross, United, Aetna, etc.) takes over your Medicare and becomes your primary insurance. You still have to sign up for Parts A/B and pay the Part B premiums. However, you will usually (but not always) get a plan that combines prescription coverage, dental, vision, fitness, along with other benefits for not much more than what you were paying for Part B.
The reason why these plans are low cost is because they can control costs by limiting choices on providers, co-pays for services, and oftentimes requiring referrals for specialists.
Although Medicare Advantage works very well for many individuals and can be much more cost effective than traditional Medigap plans, this is where the DPC conversation gets a little tricky.
Key point: If you have a Medicare Advantage plan, make sure that the plan does NOT require any referrals. Typically, PPO plans (preferred provider organizations) do not require referrals versus HMO (health maintenance organizations) plans. However, we have also seen cases where HMO plans do not require referrals so it’s important to read the fine print.
If your plan does not require you to get a referral for specialists and other services, you will be able to see your DPC doctor and she/he will be able to coordinate your care. However, if your plan does require a referral, unfortunately you will have to have a Primary Care Provider that accepts the plan you have.
When to make a decision
If you’re unsure about your decision, there are a few enrollment periods where you can choose or change a plan to coordinate with your DPC.
1. IEP (initial enrollment period)
IEP is during the first 3 months before, the month of, and 3 months after your 65th birthday. You’re new to Medicare and can choose either a Medigap/Part D or an Advantage plan available to you.
2. SEP (special enrollment period)
If you’re retiring after 65 and were on your/your spouse’s employer plan or have another special election period such as moving outside of your current plan area, you’ll be able to make a switch mid year.
3. AEP (annual election period)
AEP occurs between October 15 - December 7th. During this period, individuals on an Advantage or Part D plans can make a switch. However, in certain states such as RI (the state we’re in), switching from Advantage to a Medigap may still require medical underwriting and can be difficult if you’re unhealthy.
4. MA OEP (Medicare Advantage open enrollment period)
New for 2019, MA OEP allows individuals to make a one time switch from January 1st to March 31st. However, Medigap underwriting rules still apply if you’re looking to switch from an Advantage plan to a Medigap. Unfortunately switching from stand alone Part D plan to another Part D plan is excluded from the MA OEP.
To ensure a seamless experience between Medicare and DPC, make sure to have either a Medigap plan or an Advantage plan with no referrals.
If you’re currently considering or are seeing a DPC doctor and would like to choose a Medicare plan that fits your needs, please contact Doctor’s Choice by visiting www.doctorschoiceusa.com or giving us a call at 401-404-7373.