FAQs for Companies
Is DPC just an added cost to our plan?
DPC should be viewed as an investment that will provide a return when your company finds that the need for more expensive downstream healthcare services, like hospitalization, ER, specialist care, and pharmaceutical costs are reduced in response to highly accessible and high-functioning primary care.
How is this different than an on-site clinic?
A traditional on-site clinic continues to bill the insurance plan in addition to charging an annual fee. Many onsite clinics are “behind the fence” and don’t allow spouses/dependents to access care. Also, many have traditional business hours and don’t offer after-hours access.
Is there a long-term contract?
This depends on if you are using DPC alone or with an insurance product. Additionally, if providing DPC to your employee population requires that we build a new clinic or hire a new physician/provider, we may require a 1+ year contract. If DPC is not used with your current insurance, the agreement is typically month-to-month.
What’s a MEC?
MEC is an acronym for ‘minimum essential coverage’. A MEC-compliant plan covers the preventive benefits (found here: https://www.healthcare.gov/coverage/preventive-care-benefits/) that a qualified health plan is required to cover so that:
- individuals are exempt from paying the individual mandate penalty, and
- large employers may avoid the “non-offering employer” or “sledgehammer” penalty.
Self-insured employers pay for each out-of-pocket claim an employee makes as they are incurred instead of paying a fixed premium to an insurance carrier, which is known as a fully-insured plan. The payment of claims can be smoothed and made predictable by financing mechanisms.
Typically, a self-insured employer will set up a special trust fund to earmark money (consisting of corporate and employee contributions) to pay incurred claims. This is the definition from the Self-Insurance Institute of America, Inc.
When self-insured, how do employers shield themselves from unpredictable and catastrophic claims?
Self-insured employers may buy re-insurance called ‘stop-loss insurance’ to reimburse the company for claims above a set dollar amount that the employer may choose.
What’s the minimum company size for self insuring?
When you have 10 or more employees you can consider self-insuring.
What steps need to be taken to implement a self-insured plan? Who could set it up and administer it? Is it difficult or time-consuming or are there hidden costs when setting up a self-insured plan?
A third-party administrator (TPA) or benefits broker will be your hub to connect you with other parts of your health plan, like a physician network, pharmacy benefits manager, nurse helpline, etc.
The third-party administrator will also administer the plan. Request a transparent third-party administrator to make sure that there are no hidden costs.
Where do I find a TPA?
Please contact us and we can help with a referral.
How do I find a broker who is an expert in self-insuring?
Please contact us and we can help with a referral.
When can we enroll in DPC?
Depending on the size of your company, we could start as early as today or as late as a couple of months from now.
The larger your company and the more geographically separated your company is, the more upfront planning is required for a smooth onboarding experience.
How much cash do I need on hand to cover the health-claims costs of a self-funded insurance plan?
If you are self-insured, you can have an analysis completed by an actuary that can give you an estimate of what you should be prepared to cover in any given month.
If you have level-funding self-insurance, your monthly costs are fixed and you don’t need to worry about cash flow issues.
Do employees have to give up their current primary care physician?
Employees do not need to give up their current PCP.
What if I have employees in different areas of the state or country?
We offer virtual direct primary care for your employees that may live or work in different parts of Texas. With telemedicine (Virtual DPC) those patients:
- have access to their own direct primary care physician 24/7
- get discounts on labs/tests, and
- receive guidance through the healthcare system.
If you have employees in other states, our affiliate–My MD Connect–can help those patients as well.
What are the downsides/risks of self-funded insurance and DPC?
There are nuances to self-insuring that don’t exist in the fully insured world. As long as you know where the risks lie, you can prepare for them or circumvent them entirely.
Examples of issues that incompletely informed executives may be surprised by include:
- guaranteed quotes, and
Run-out is how your plan will pay for claims after you have broken ties with your stop-loss provider. For example, if the final date for your plan is 12/31/17 and your employee sees their doctor on 12/30/17, the doctor’s bill will not likely be submitted until after the plan termination, even though the service took place when the plan was in effect. A typical run-out extends out 6 months after your plan terminates. You can contract with your current stop-loss provider to provide the run out.
It is possible that a stop-loss provider can decline to quote a rate for stop-loss insurance. That being said, the employer can request a contract provision that would require a quote from the existing stop-loss provider.
A laser is used when a stop-loss provider wants a different (higher) level of stop-loss for a particular individual. In this situation, the employer would be asked to pay for all claims below the stop-loss level.
DPC is relatively risk free. The rate is capitated (a medical provider is given a set fee per patient) and the services and fees are transparent.