Medicare and DPC

My patients with Medicare can come from very different circumstances.  Direct Primary Care (DPC) can potentially provide the best quality primary care at the lowest price, but it takes some consideration and probably discussions with competing insurance agents as to what options might be best for you. Medicare insurance policies allow for patients to shop around and change their insurance policies during Open Enrollment, which occurs annually. In 2014, Open Enrollment started Oct 15th and ran through Dec. 7, 2014.

Because I have opted out of Medicare in order to follow the DPC model, Medicare will not allow me to charge or seek reimbursement for my services in any way.  Furthermore, Medicare will require that you sign a waiver that You will not seek any reimbursement from Medicare for my services.  This will NOT affect your usual Medicare transactions with other Medicare providers (such as specialists, lab or diagnostic testing, hospitalization, ER, etc). 

We have prepared our formal Medicare waiver form. Find it under the "Forms" page; link to it here; or expect to sign one at your first office visit at Twardon Family Care, PLLC.

Basic Medicare Costs and Medicare Supplements

Every patient turning 65 needs to enroll in Medicare, in order receive the opportunity to get the benefits (partial financial coverage for hospital and doctors' costs). Medicare will collect a monthly fee called a premium (usually deducted directly from Social Security checks, so many don't even see this charge), which in 2014 was $104.90 (it can be more for high income persons).

Paying this premium allows the patient to claim partial financial coverage, generally 80% of Medicare-allowed charges, and the patient will be responsible for the remaining 20%.  The 20% of a hospital bill, or even a regular primary care provider using Medicare Fee Schedules, can still add up to very large expenses. A hospitalization with charges of $100,000 (like a car accident needing surgery; or cancer diagnosis with chemotherapy) could cost patients $20,000, even on Medicare.  Thus, most Medicare patients enroll in various Medicare Supplemental insurance (sometimes called "Medigap" coverage) or programs that replace Medicare altogether ("Medicare Advantage" plans). 

Medicare supplemental or replacement insurance plans can be offered by different companies, but they have to follow different structures mandated by the government regarding covered services; deductibles (the amount a patient has to pay out of pocket before the insurance will begin to pay); and copays (money a patient may need to pay at the time of a visit).  The companies then try to get business by offering the lowest premiums, but this can often cost $100 to $200/month or more.  These premiums are in addition to the universal Medicare premium.

Click HERE for a link to the official Medicare webpage regarding costs.

Then click HERE for the official Medicare webpage regarding Medigap/Medicare Supplemental insurance vs Medicare Advantage/Medicare Replacement insurance policies.

Click HERE for Consumer Reports comparison of Medigap and Medicare Advantage.

The government and the insurance companies have allowed this system to become VERY COMPLEX.  You need to have a very good understanding of your options before making any change in your insurance, but a patient can easily be paying hundreds of dollars a month, and you want to choose a plan that will give you the best value for your money, and still adequately cover for the risk of catastrophe.  This is a personal decision.  I am not a financial advisor or insurance agent, but I would consider the following.

  • If you aren't enrolled in an insurance plan, Medicare or otherwise, then seriously consider getting coverage (not for me-- I won't be taking insurance-- but the costs of catastrophic illness can be overwhelming to almost anyone).
  • If you have basic Medicare without a supplement, seriously consider some form of extra coverage (again, even 20% of a very expensive hospital bill or a year's worth of clinic charges, especially with any additional "facility fees" that hospital-based outpatient practices, can still be ruinous to a personal budget).
  • Seek careful advice from insurance agents and/or financial advisor, and do not make any change without considering the risks and benefits.
  • Consider whether choosing a Medicare supplement or replacement with a higher deductible AND lower premium could save you more money over the year.

Medicare Advantage Plans

One particular distinction of Medicare Advantage Plans is that they replace Medicare instead of supplement the basic Medicare plan offered through the government, and the company may not necessarily impose all the same restrictions seen with basic Medicare (with or without Medicare supplements [Medigap]). 

Specifically, when a Medicare patient takes out a Medicare Advantage policy, then the private insurance company (like Blue Cross/Blue Shield) receives the premiums instead of Medicare.  The private insurer is then responsible for administering the coverage benefits.  Medicare is not directly involved in transactions, and this means that such companies potentially could reimburse for my services (in a way that Medicare will not). However, you always need to confirm what a particular insurance policy will honor.

One Insurance Agency Familiar with Structuring Medicare Supplements and Advantage Plans

I reached out via service numbers from the web to several major insurance companies, including United, Coventry, but the only company with a local in-town presence that could meet with me was Blue Cross/Blue Shield (BC/BS).  I met with representatives of WNC Health Insurance (telephone 828-681-8223) who sell BC/BS policies, including Advantage Plans.  The representatives there offered their assistance in explaining options. 

I met several people who think that other insurance companies will be increasing their offerings for Medicare Advantage Plans in the near future, but I'm not aware of any specifics at this time.