Direct Primary Care: What About Insurance?

Through our direct primary care model, patients can access healthcare with an affordable membership fee. Because our direct primary care clinic is different from traditional primary care models, we often get questions related to insurance. Here’s a list of frequently asked questions about insurance to help you.

Frequently Asked Questions about Insurance:

What is the Affordable Care Act?

The Affordable Care Act (ACA) is a comprehensive healthcare reform law. Under the law, a national healthcare marketplace was established at HealthCare.gov that offers three tiers of insurance plans: Bronze, Silver, and GThrough our direct primary care model, patients can access healthcare with an affordable membership fee. Because our direct primary care clinic is different from traditional primary care models, we often get questions related to insurance. Here’s a list of frequently asked questions about insurance to help you.

Is Integrative Family Medicine of Asheville (IFMA) ‘outside' of the insurance model?

We do not bill insurance. We do provide our patients with all of the documentation necessary to submit to the insurance company for reimbursement. Please note that services at IFMA are not billable to Medicare or Medicaid. Our Direct Primary Care model pairs quite well with high deductible health plans (HDHP) such as the Affordable Care Act Bronze level plans. Depending on your situation, this combination may provide better care for significantly less than a more comprehensive plan such as Silver, Gold, or Platinum.

How does the Integrative Life Membership (ILM) work with the Affordable Care Act (ACA)?

The ILM is our approach to comprehensive primary care. It pairs well with the ACA in a number of ways.

For some patients, the Catastrophic or Bronze level plans are the most affordable ACA options, and the ILM provides the attentive, person-centered primary care coverage that these plans can lack. Often the monthly ILM fee of $69 is less than what it would cost for the next level plan that provides primary care. This would depend on your level of subsidy, though it is possible that you can have better primary care for less money by pairing the ILM with the right ACA plan.

For Medical Sharing Programs, the ILM qualifies for primary care services and aligns well with the preventive lifestyle approach that these programs often emphasize.

For all patients, the ILM provides more comprehensive, personalized primary care than traditional offices can provide. We have many patients with top-tier insurance, who come to us for the quality of care, personal attention, integrative approach, longer visits, and short waiting time. The ILM is an excellent value for care that aligns with your values.

Do you recommend getting health insurance?

We recommend that individuals have at least a high deductible health plan (HDHP) to insure them in case of a major emergency. We liken this to home or car insurance. You would have insurance to cover the major roof repairs or auto accidents, but would handle the routine maintenance and prevention out of pocket.

Now with the ACA, individuals and families may be eligible for tax credits and cost-sharing subsidies. This makes health insurance accessible to new populations that are in need. Some will receive significantly lower rates, yet others’ rates may increase 3-7 times from their previous coverage.

What is the benefit of changing our relationship with insurance companies?

Medical practices must pay for many administrative costs associated with insurance, such as coding, filing, billing, and so on. Many primary care physicians must see more patients per day just to cover their overhead expenses. This results in shorter visits and less comprehensive, less personalized care for patients. It leads to a system that all too often treats symptoms instead of roots causes of illness and prescribes medication instead of addressing the whole person.

Studies have repeatedly shown that longer visits yield better outcomes. By not billing insurance we can provide longer visits, see fewer patients, and address the roots of your concerns in personal ways that lead to sustainable health.

Does a membership count as insurance for the ACA?

The membership does not qualify as stand-alone insurance under the ACA.

The membership provides access to care often not covered under many ACA plans. If you combine your membership with a medical cost sharing plan through Liberty Direct, then you will be exempt from the ACA requirement and you will not be fined.

Members often save money by combining our services with high deductible plans or medical cost sharing plans. The HDHP plans serve as ‘wrap-around’ insurance for major events that might require procedures or hospitalization. The membership can take care of your everyday health needs, including treating chronic medical conditions. This is similar to using car insurance to cover for big accidents, but paying out of pocket for the routine maintenance and upkeep.

How do I seek reimbursement with my insurance company?

While IFMA does not file costs through insurance, you may submit your in-office charges to your insurance provider (excluding Medicare and Medicaid) for out-of-network reimbursement. While each insurance company may have different requirements, most out-of-network claims involve completing a simple form—usually obtainable by searching for “reimbursement form” for your insurance carrier—and providing documentation through an itemized receipt or invoice. We can provide all of the required information so that you may submit your insurance claim yourself in an itemized invoice.

  • The form for BCBS of NC is here.
  • The form for Coventry One is here.

At the time of your visit, please let us know that you are going to seek reimbursement. This helps us optimize your reimbursement rate.

How much will I be reimbursed?

Because our visits are significantly longer, involve health coaching, and are more comprehensive, we find that our patients receive excellent reimbursement. The rate of reimbursement will depend on your plan, the deductible, and level of co-insurance for out-of-network providers.

Can I submit my monthly or yearly ILM fees for reimbursement?

If you pay in full for your ILM year (a total of $828) when you receive your establish care visit or annual physical exam, we can bill the membership charge as a Comprehensive Physical Exam. Your comprehensive exam is included as one of the benefits of your annual ILM membership, and this visit type is eligible for insurance reimbursement at an out-of-network rate determined by your insurance provider.

When paid monthly, membership dues are ineligible for insurance reimbursement since the costs are not associated with specific visits or insurance procedure codes. Furthermore, since establish care and annual exams are included in the membership for a $0 visit cost, when you pay monthly for your membership dues, there is no visit fee which can be reimbursed for those exams.

By paying for the ILM upfront for the year at your establish care or annual exam (Comprehensive Physical Exam) and submitting for reimbursement, you can recover much of the expense of joining. This is the best both worlds: cost savings and better care. We will provide all of the documentation for you.

Liberty Healthshare will reimburse up to $60 of the monthly dues for those patients who choose to pair our membership with this cost sharing ministry.

Can I submit my visits to Medicare or Medicaid?

Due to current legal guidelines, our services cannot be submitted to Medicare or Medicaid for reimbursement. We are able to provide an integrative holistic health consultation for these patients; however, this is a non-billable service for Medicare and Medicaid. We do have a number of Medicare patients that choose to see us for the quality of care and length of visit that they receive. All Medicare and Medicaid patients are required to sign an agreement stating that they understand that visits at IFMA are not billable to Medicare/Medicaid.

Can I bill my labs through insurance?

As a Direct Primary Care (DPC) practice, IFMA consciously does not bill insurance for lab work or office visits. If you would like to file any lab work costs with insurance, you may request a copy of your paperwork to submit to your insurance provider for reimbursement. We can make no guarantees concerning rates of reimbursement as they are dependent upon each patient’s insurance provider and plan.

We will only bill Medicare for lab work that is $60 and up per test (panels excluded). Panels are comprised of individual tests and therefore not included as billable; only the cost of a qualifying individual test may be submitted. Excludes specialty and hormone testing; we do not bill Medicare for these labs.

Studies done outside of IFMA such as X-rays, MRIs, and CT scans can be billed directly to insurance through the organization performing the study. You may have copays or deductibles depending on your plan.

Do you handle prior authorizations?

Insurance companies may require prior approval before performing expensive procedures, diagnostic tests, or prescribing non-generic medications. This is a cost containment measure for them, however it can be very time-consuming for medical offices. Staff may spend a lot of effort faxing, discussing the case on the phone, and conferring with physicians before the item is approved. This process is known as a ‘Prior Authorization.’

Studies have demonstrated that this tactic may decrease overuse of expensive options, though it is a significant expense passed on to medical offices.

We have the following prior authorization policy:

For all patients, we perform procedures and seek diagnostic studies only when medically necessary. We treat your concerns with the most natural methods possible, and when a medication is required we will seek to use the most cost-effective option. For ILM members, we will provide 10 minutes of staff time for each prior authorization before you incur additional fees based on the required staff resources. For non-ILM patients, you will be charged for the staff resources required.

It is unfortunate that we are not able to circumvent this process. If there is a procedure, diagnostic test, or medication that is medically necessary, we will work hard for you to get what you need.

What are the ACA plan levels?

The plan levels are symbolized by the metals bronze, silver, gold, and platinum. They increase in coverage and monthly premium in that order. The level of plan that is best for you will depend on:

  • Your healthcare needs
  • Your level of subsidy
  • Your preference or style of medical care
To better understand the metal levels, watch this clip from BCBSNC:

As seen in the video, a key difference is the co-insurance level. Co-insurance is the amount that you are responsible for paying. Co-insurance kicks in for services covered with no deductible or after you have met your deductible. The deductible and covered services vary from plan to plan, though all plans cover the Essential Health Benefit (explained below). The metals levels follow this basic layout with Bronze level being the most affordable and Platinum being the most expensive:

  • Bronze co-insurance 40%/ insurance pays 60%
  • Silver coinsurance 30%/ insurance pays 70%
  • Gold coinsurance 20%/ insurance pays 80%
  • Platinum coinsurance 10%/ insurance pays 90%

For healthy individuals that do not qualify for a ‘Silver-enhanced’ plan, a Bronze plan with a higher deductible might be the most economical, appropriate choice. For individuals that may require a lot of health are over the year, a higher level plan with more included services may be more appropriate. This is where you need to evaluate your healthcare needs, as well as the style of care you would like to receive.

If you do not qualify for a ‘Silver-enhanced plan’ the difference between the Bronze plans and the Silver plans offering primary care visits, is often more than our monthly ILP fee. Pairing the ILP with a higher deductible Bronze plan, and possibly even a Health Savings Account (HSA), is a good option for having care that aligns with your values at a lower price.

The HSA option is available paired with specific ACA qualified plans. The HSA lets you have additional control of your healthcare dollars to use on qualified expenses that may not be covered by your plan such as Acupuncture or other services. Visit these sites for more information about qualified expenses: HSA Center and IRS.

In North Carolina there are two insurance companies offering plans on the Health Insurance Exchanges: Blue Cross Blue Shield of North Carolina and Cigna. To qualify for subsidies, plans must be ACA compliant, so make sure that you purchase a qualified plan. The easiest ways to know for sure is to purchase through the health insurance exchange at HealthCare.gov, to work directly with an agent, or to work with a navigator.

 

Are some insurance plans a better fit for IFMA members?

After hearing stories from a number of our patients, we can advise you that it is worth reading the fine print. While we are not insurance agents, we can relay the experience of some of our patients. Some of the plans, which are typically the most affordable ones, have very limited referral networks and limited routes to receive necessary care should the occasion arise. The plans that fit best with our clinic allow out of network providers to make referrals and prescribe medication.

What about Catastrophic Health Plans?

Before the ACA, Catastrophic and High Deductible health plans were often very similar, but today there are some key differences between the two. Only certain types of individuals are currently eligible for a Catastrophic plan. According to HealthCare.gov, Catastrophic health insurance plans have low monthly premiums and very high deductibles. Though they provide coverage in the event of serious illness or injury, Catastrophic plan holders pay most of their own routine medical expenses. The only people who qualify for a Catastrophic plan are those under the age of 30 and individuals of any age with a hardship exemption or affordability exemption.

Catastrophic plans are not available in all areas, and sometimes are actually more expensive than the Bronze level plans. Make sure that you examine the fine details of any plan that you are considering carefully.

Unanswered questions? Contact a health insurance navigator through the references below:

NC Navigator Consortium: 1-855-733-3711 or ncnavigator.net

Pisgah Legal Services: 828-253-0406 or pisgahlegal.org

The Council on Aging of Buncombe County: 828-277-8288 or coabc.org

Hummingbird Insurance: 828-372-0101 or [email protected]. We recommend Geoff Ferland.

You can also contact a local insurance representative that can meet with you to discuss your situation. These representatives work off of a commission from the insurance company. It will not cost you anything and should not increase your insurance rate.

Insurance representatives will present their organization’s plans. Consider the insurance company that you would like to use, and choose a representative from that organization. Only a few companies are offering ACA plans in North Carolina. To receive the subsidies, you will need to make sure that the representative is signing you up through HealthCare.gov. This will help avoid any confusion and accidentally signing up for a plan lacking the subsidies that you may be eligible to receive.