Healthy groups should be rewarded with affordable premiums, and now there is a group health insurance plan coupled with Direct Primary Care which does just that. You deserve the opportunity to gain the knowledge necessary to make an informed decision regarding your group’s health insurance plan. We at Republic of Texas Insurance Group want to share with you the dynamic emerging movement of Direct Primary Care which combines Direct Primary Care and an employer-based health insurance plan.
What is Direct Primary Care (DPC)? DPC is essentially the restoration of comprehensive care in the doctor-patient relationship without the constraints of health insurance. It is a throwback to a time when an individual generally carried catastrophic insurance to cover costly major events, and paid their Primary Care Physician (PCP) out-of-pocket as needed. Neither the patient nor the physician should feel rushed during a visit, and physicians should be able to diagnose and treat their patients in a comfortable, relaxed environment.
What does a DPC physician offer that a standard Primary Care Physician (PCP) does not? A higher level of care without the time constraints to which a PCP who accepts insurance is subject. The DPC physician’s services are retained at an affordable monthly fee agreed upon by the physician and employer. This will prove vital later in the conversation. A DPC physician treats far more conditions in-office, drastically reducing the need for referrals to specialists.
If DPC physicians do not accept insurance, how will your employees be covered in the event of a major health-related event? There needs to be a safety net in place in the event something catastrophic occurs. By carrying a group health insurance plan in addition to utilizing a DPC physician, your employees are now covered for conditions both large and small. The vast majority of conditions are treatable by the DPC physician, but the plan provides coverage for those conditions which are not.
What are the details of the group health insurance plan? The plan is a high-deductible, partially self-funded plan. The highest deductible is 5k, with a 3.5k, or zero dollar deductible option with gap insurance. Now, imagine a pie with three pieces. A percentage of the group’s monthly premium will be allocated to each of those three pieces: administrative, carrier profit, claim fund. The term partially self-funded means the employer retains some of the risk when a percentage of premium dollars are allocated to the claim fund. The claim fund is only accessed in the event a specialist is required, or there is a catastrophic event. Out-of-state employees may qualify for coverage as well.
Why is the claim fund so important to the employer? Every unused dollar in the claim fund at the end of the policy term is returned to the employer tax-free, as long as the employer continues to use those funds for employee benefits, making it highly beneficial to the employer if the claim fund is accessed at a minimum.
How is the claim fund protected without sacrificing employee benefits? This is where the DPC physician plays such a vital role. PCP’s typically file 75-85% of health insurance claims, but a DPC physician files no claims while treating more conditions, increasing the odds the claim fund remains intact.
What if an employee’s condition requires a specialist? There is no network associated with the plan, so the employee is free to see the specialist of their choice.
What happens in the event there is a large claim? If a claim is large enough, the patient meets their deductible and maximum yearly out-of-pocket, co-insurance from the carrier covers 100% of the remainder of the claim. No one claim can drain the entire claim fund as there is stop-loss coverage built in which allows only a certain amount of claim fund dollars to be used per claim.