DPC Frequently Asked Questions
Take a moment to explore the benefits of Dr. Lucatorto's Direct Primary Care practice so you can decide whether or not it is the right choice for you. You can find the answers to some of the most frequently asked questions below. If you would like more information, please call our practice administrator, Denyce at 973-663-8899.
Q: How does DPC differ from traditional primary care?
A: DPC is an alternative practice model. This is a new primary care health care option that does not bill your insurance. This means you no longer have to deal with copays, deductibles, and coinsurance. There is a flat monthly fee, which provides improved access to your physician.
You will see and feel the difference immediately when you visit us at Morris Sussex Direct Family Practice. We have designed a relaxing and comfortable space. Office visits will never feel rushed so we can take the time to address your health concerns and questions. We limit our practice to a few hundred patients per doctor, far below the national average of 2,300 in most primary care practices today. With a smaller practice, we really get to know our patients, so we can take a more proactive role in your health and wellness, and be there when you need us. Our goal is to provide you and your family with an experience that will not just meet, but exceed, your expectations for a doctor’s office.
Q: Is there a limit to how many patients can join Morris Sussex Direct Family Practice?
A: Yes. One of the most important aspects of direct primary care is limiting the practice size to be able to devote more time and energy to each patient. Therefore, once we have reached our ideal practice size, we will establish a waiting list.
Q: Will the DPC practice accept my insurance?
A: The new practice does not bill insurance. The only cost will be the membership fee. You will have no copays, deductibles, nor coinsurance.
Q: Is DPC the exact same thing as concierge medicine?
A: No. Although both models charge a membership fee, DPC is ordinarily less expensive, while also covering the cost of office visits with your doctor. Concierge medical offices typically charge a high monthly fee, in addition to charges associated with insurance billing, including copays, deductibles, and coinsurance.
Q: What are the benefits of DPC?
A: Enhanced access to your physician, extended visits, guaranteed same- and next-day appointments, and on-demand video visits for improved convenience and access.
Q: Who does this membership plan work best for?
A: It works especially well for those who want to participate in improving their health and staying well, including:
* Patients desiring easy and direct communication with their doctor
* Patients who want a doctor to address the root cause of illness, not just treat the symptoms
* Those with high-deductible health plans, Health Sharing accounts, Health Savings accounts, PPOs or no insurance
* Self-insured businesses seeking to provide their employees with affordable health care and improved well-being, while simultaneously reducing everyone’s healthcare spending. Everyone benefits from the value-added services we offer at Morris Sussex Direct Family Practice.
Q: Can a DPC practice treat patients with insurance coverage?
A: Yes. We can see patients who have insurance. Additional services outside of our scope, including diagnostic imaging and laboratory studies, will be covered by your traditional insurance plan.
Q: How do I pay?
A: The membership fee will be collected monthly via credit card or debit your checking.
Q: Can Health Savings Account funds be used to pay the DPC membership fee?
A: No. However, there currently is pending legislation in congress to recognize HSA and FSA funds within the DPC model.
Q: Can joining Morris Sussex Direct Family Practice actually save me money?
A: While every patient’s situation is unique, it is likely that many patients will save money at our practice because we can handle the vast majority of your health issues and concerns.
Across the country, research and published findings show the direct primary care model can lead to:
* Less need for expensive testing * Less unnecessary medications * Savings on labs and imaging
* Fewer specialty referrals * Fewer emergency and hospital visits
By switching to a higher deductible, lower premium plan, we can actually help many of our patients save money.
We also have negotiated discounts with local labs and radiology providers for our patients who choose to pay cash for these services. AND you will know what the price will be BEFORE any such service is performed.
Q: Will I still benefit from membership even if I don't expect to need frequent medical attention?
A: Absolutely. Our focus at Morris Sussex Direct Family Practice is on preventive care, lifestyle modifications, screenings and risk assessments. We want to identify and prevent disease before it starts, concentrating our efforts on long-term health and wellness. We listen carefully to you to understand how your life, work and family may be affecting your health. Together we create a personalized plan to achieve and maintain your optimal health and goals. Advanced diagnostic tests can help us identify risk factors and health issues before they cause disease, saving you money, time, suffering and higher costs in the long run. Unlike the traditional practice environment, we have the time to deliver this type of comprehensive and detailed care.
Q: Do I still need to have health insurance?
A: Yes, you do. Our medical practice is NOT a health insurance program. It is very important to maintain insurance (and/or Medicare) to cover expensive, unusual and unpredictable events such as surgery, emergency care and hospitalization – BUT NOT for routine primary care! The current insurance-based healthcare system actually makes primary care MORE expensive, difficult and less effective, too. Our practice does the opposite. By charging a set fee, we can spend more time with you and focus on your individual health needs to maintain and improve your health. We want you to see us as often as you need to, because our goal is healthy and happy members!
Q: What if I need urgent care?
A: If you have a life-threatening emergency, call 911 immediately. A family member or caregiver can call us later so we can be in contact with the emergency room.
For urgent problems that are not emergencies, you can contact us 24 hours a day, 7 days a week. In many cases, we can diagnose and treat your need without a visit to the ER. In fact, direct primary care has been shown to result in fewer ER visits for members because we can discuss urgent medical needs any time of the day or night, and you know you can see us the next day!
Q: What happens if I'm admitted to the emergency room or hospital?
A: Emergency room visits and hospital admissions for serious medical problems are stressful and often confusing for patients and their families. Direct communication with someone who knows you and your medical history can be critical at these times. At Morris Sussex Direct Family Practice, we’ve got your back! We will contact your emergency room physician and/or anyone providing care during your hospitalization to make sure they have the most accurate and up-to-date information they need to treat you. As your health care advocate, we will communicate with you and your loved ones. We will also be in the best position possible to provide your post-hospital care.
Q: How do I get in touch with you? May I contact you anytime?
A: For routine matters the office is open 9am-5pm Monday through Friday. Whether you call during or after business hours, you can expect us to either answer the phone or return your call shortly.
Your monthly fee covers services we perform, plus gives you access to discounted labs and radiology. We offer complete price transparency – without the insurance middleman – and potential savings, too.
The flat monthly fee covers everything that can be done in our office or via a virtual visit including wellness visits, sick visits, routine gynecology care, chronic disease management, and coordination of care with specialists and during hospitalization. In addition, we provide in-office lab testing and a variety of procedures such as joint injections, skin biopsies and cryotherapy – all at no additional cost to you.
Under the direct primary care model, we no longer depend on health insurance reimbursement to pay for our services, so we do not bill your insurance. That means you do not need to pay co-pays or deductibles for your primary care, and you won’t get any surprise bills from us
NOTE: There is a one time enrollment fee of $75 per individual, maximum enrollment fee of $225 per family.
Minimum membership length is 1 year.
* With participating adult guardian.
Making Direct Primary Care Work With Medicare
Direct Primary Care (DPC) is becoming more popular among baby boomers looking for affordable concierge-level healthcare. However, many patients on Medicare are struggling to find compatible insurance plans that support DPC practices. In this cheat sheet, we'll provide you with some valuable information about Medicare and how to choose the right plan to complement your DPC doctor.
What is Medicare?
Medicare is a federal health insurance program for individuals aged 65 and over, disabled for 24 months, or with certain conditions. Medicare is divided into several parts, including:
* Part A: Hospitalization coverage * Part C: Medicare Advantage plans
* Part B: Outpatient services coverage * Part D: Prescription drug coverage
Most people who have paid 40 quarters into the Medicare system via payroll taxes pay $0 for Part A, while Part B costs $164.90/month (2023), with the possibility of a higher rate based on income. There is also a $1,600 (2023) deductible for Part A and a $226 deductible plus 20% coinsurance for Part B.
Breakdown of What is Covered by Medicare Parts
Medicare covers a wide range of medical services and supplies, including hospital stays, doctor visits, preventive services, diagnostic tests, medical equipment, and prescription drugs. Here is a breakdown of what each part of Medicare covers:
• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and home health care.
• Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, diagnostic tests, and medical equipment.
• Part C (Medicare Advantage): Offers the same coverage as Parts A and B, but is provided by private insurance companies. May also include additional benefits such as dental, vision, and hearing.
• Part D (Prescription Drug Coverage): Covers prescription drugs and is provided by private insurance companies.
It's important to note that while Medicare covers a lot of medical expenses, there are still some services and supplies that it doesn't cover, such as long-term care, dental care, and cosmetic procedures.
To fill in the gaps of Medicare Parts A and B, some individuals choose to enroll in a Medigap (or traditional Supplemental Plan) along with a standalone drug plan (Part D). Common supplemental plans include Plan C, F, G, and N. These plans provide more flexibility in choosing providers and protect against high costs like hospitalization and outpatient surgeries. However, the monthly price of a Medigap plan is usually higher than other options.
Key point: Medigap plans work well with DPC practices because they supplement Medicare Parts A/B. While Medigap plans do not cover the cost of your DPC doctor, your DPC doctor can still coordinate your care and recommend services without the need for referrals.
Medicare Advantage Plans
Medicare Advantage plans (Part C) is essentially privatized Medicare. Private insurance companies like Blue Cross, United, Aetna, and others take over your Medicare and become your primary insurance. You still have to sign up for Parts A/B and pay the Part B premiums, but you usually get a plan that combines prescription coverage, dental, vision, fitness, and other benefits for a lower cost than traditional Medigap plans.
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.
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, make sure to read the fine print, as some HMO plans may not require referrals. If your plan does require referrals, you will have to choose a Primary Care Provider that accepts your plan.
Does Direct Primary Care Work With Medicare?
Medicare won’t cover your membership fee for a direct primary care arrangement.
Many DPC providers don’t accept Medicare or any other insurance for services. For Medicare, this is called “opting out.” Medicare won’t reimburse you for any services from a provider who opts out unless it’s an emergency.
You can’t use Medicare to pay for DPC, but you can still use Medicare to pay for covered services from other providers. For example, you might get all of your primary care from a DPC practice, but you could use Medicare Part A to cover a hospitalization or major surgery.
Medicare Part A is a good fit alongside DPC because it’s free for most people, so you’re not paying any extra premiums for the coverage. After a deductible of $1,600 in 2023, Medicare Part A covers inpatient services, and there’s no copay until you’ve been in the hospital for more than 60 days.
How Direct Primary Care Affects Your Medicare Coverage?
Using direct primary care doesn’t change what Medicare does or doesn’t cover, but it might influence the choices you make about your Medicare coverage. Because Medicare Part A is free for most people, there’s probably no reason not to use Part A along with DPC. Beyond that, it gets a little trickier.
Medicare Part B — which covers outpatient services, but not direct primary care — isn’t free. There’s a significant monthly premium: $164.90 per month in 2023, whether you use it or not, and you still owe that premium if you sign up for Medicare Advantage.
You could opt out of Medicare Part B to avoid paying the premium, but there could be a penalty for doing so. Going without Medicare Part B or similar qualifying coverage from an employer after you become eligible for Medicare means you’d owe steep, permanent penalties if you ever sign up for Part B in the future.
DPC memberships don’t cover prescription drugs, so a Medicare Part D plan can be a good way to get prescription drug coverage. Some DPC practices dispense certain medications at wholesale prices, but those arrangements don’t count as prescription drug coverage, which Medicare beneficiaries need to maintain in order to avoid the Medicare Part D penalty.
Is Direct Primary Care a Good Idea for Medicare Beneficiaries?
Direct primary care could be a good option if you’re looking for a health care provider who can spend more time working closely with you and you can afford the membership fees.
There are several considerations that Medicare beneficiaries should note when considering direct primary care:
• Most DPC practices charge their highest fees for older patients, so make sure you can afford the monthly expense.
• You’ll probably need to rely on other coverage to pay for hospital care, prescription drugs and services not covered by a DPC contract.
• You’ll need to pay for both Medicare Part B and Medicare Part D to avoid their respective late enrollment penalties, even if you’re not using them to pay for services or medications.
In short, using direct primary care could be a way to get more hands-on care, but it requires a subscription fee on top of what you pay for your Medicare coverage. Whether it’s worth it for you depends on what value you put on the closer relationship with a DPC provider.
What Does Direct Primary Care Cost?
The average monthly fee for an adult is between $65 and $85, depending on age, according to a 2020 market survey of about 200 DPC providers conducted by Milliman Inc. for the Society of Actuaries. Because fees tend to go up according to age, older adults on Medicare tend to be at or above the high end of that average. Here are a handful of real-world examples of DPC providers’ advertised fees for patients age 65 and older:
• Elevated Health of Huntington Beach, California, charges $125 per month.
• Dedicated Family Care of Fitchburg, Wisconsin, charges $110 per month.
• Morris Sussex Direct Primary Care, Lake Hoptacong, NJ charges $100 per month.
Some practices also charge one-time registration or enrollment fees, which often cost about $100 per person.
Dr. Lucatorto charges a registration fee of $75. Additional charges for covered services are rare.
When to Make a Decision
If you're unsure about your decision, there are several enrollment periods where you can choose or change a plan to coordinate with your DPC.
• IEP (initial enrollment period): During the first three months before, the month of, and three 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.
• 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.
• AEP (annual election period): AEP occurs between October 15 - December 7th. During this period, individuals on Advantage or Part D plans During this period, individuals on Advantage or Part D plans can make a switch. However, in certain states, 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): this period 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 a stand-alone Part D plan to another Part D plan is excluded from the MA OEP.
• SEP for D-SNPs (Dual Eligible Special Needs Plans): If you’re eligible for both Medicare and Medicaid, you may be able to enroll in a D-SNP which provides extra benefits for individuals with both Medicare and Medicaid. The enrollment period is year-round.
As more physicians retire and switch to Direct Primary Care practices, it’s important for Medicare beneficiaries to understand their options and make informed decisions when selecting a plan. Medigap plans work well with DPC practices because they supplement Medicare Parts A/B and allow you to see any doctor/hospital that takes Medicare with no referrals. However, they can be expensive. Medicare Advantage plans can be a more cost-effective option but make sure that the plan does not require referrals, or you will have to find a primary care provider that accepts your plan. Remember to take advantage of the enrollment periods to make any necessary changes to your plan. By being informed and proactive, you can make Direct Primary Care work for you with Medicare.