How Direct Primary Care Works With Your Health Insurance

One of the questions we hear most often: “I already pay for insurance. Why would I pay for a membership too?”

It’s a fair question, and here’s the short answer. Insurance and direct primary care do different jobs. Insurance protects you from big, unpredictable costs like a hospital stay, surgery or a cancer diagnosis. Direct primary care gives you a physician who knows you, has time for you, and can see you when something comes up. Most people need both. The problem is that traditional primary care has been squeezed into 12-minute visits run by insurance billing.

Here’s how the two fit together at Upper Echelon Medical.

What Your Membership Actually Pays For

In an insurance-based clinic, every visit gets coded, billed and adjudicated. That system decides how long you get with your doctor, and it usually isn’t long.

At UEM, your membership fee pays for direct access to your personal physician and care when you need it. With no billing middleman, membership includes:

• Unlimited, unrushed clinic visits. No copays and no 15-minute clock. Our physicians keep small patient panels on purpose.
• Telemedicine consults when you don’t need to come in.
• Discounted lab tests and EKGs, often a fraction of what gets billed through insurance.
• Wholesale pricing on medications, plus negotiated cash rates on imaging and procedures.
• Member pricing on add-on services: DEXA body composition scans ($25 for members vs. $65 otherwise), bone density scans, mobile blood draws, home visits, IV hydration, sports physicals and osteopathic manipulative treatment.
• Care coordination. When you need a specialist, your UEM physician makes the referral and stays involved. You don’t get handed off and forgotten.

Individual membership is $150/month. Current initiation fee and family pricing are here.

Where This Model Pays Off: Chronic, Ongoing Problems

Take borderline high blood pressure. In a typical clinic, you get one visit, maybe a prescription, and a follow-up in three months if you can get on the schedule.

At UEM, you and your physician review your home readings together, look at sleep, nutrition, stress and training, and adjust as you go. Your physician can also put real numbers to your metabolic health. Our in-office iDXA measures visceral fat and lean mass, which tell you a lot more about your cardiometabolic risk than the scale does. That’s root-cause medicine, and it only works when your physician has the time and continuity to follow through.

Why You Should Keep Your Insurance

DPC isn’t insurance, and we never advise members to drop their coverage. Your insurance still covers:

• Emergency room visits and hospitalization
• Surgery
• Specialist care
• Advanced imaging (MRI, CT)
• Prescriptions you choose to fill through your plan

Many of our members pair UEM with a high-deductible health plan (HDHP). That usually lowers premiums, and in 2026 it opens up a real tax advantage.

New for 2026: You Can Pay for DPC With Your HSA

As of January 1, 2026, federal law (the One Big Beautiful Bill Act) lets you:

1. Keep contributing to your Health Savings Account while you’re a DPC member. Before, a DPC membership could disqualify you.
2. Pay your DPC membership with HSA dollars, tax-free, up to $150/month for an individual or $300/month for a family.

UEM’s individual membership falls within that limit. For many patients, that means the membership is paid with pre-tax money.

One thing to watch: IRS guidance (Notice 2026-5) says DPC fees do not count toward your HDHP deductible or out-of-pocket maximum. Budget for the membership separately from what you expect to spend on insurance-covered care. Confirm the details with your HSA administrator or tax advisor before you rely on them.

What Using Both Looks Like in Practice

Labs: Your UEM physician can show you our cash price next to what your plan would charge. Sometimes cash is cheaper even after insurance. Sometimes running it through insurance makes more sense because it counts toward your deductible. We’ll help you figure out which one is better for you.

Specialists and imaging: Your physician will refer you and send the right records. Before you book, check with your plan about network status, prior authorization, and whether an HMO needs the referral to come from your assigned plan PCP. A referral from your UEM physician doesn’t guarantee your insurer will cover the visit, so our team will help you get through that.

Urgent issues: Because you can reach your physician directly, a lot of the “should I go to the ER?” moments get handled with a message or same-week visit. Avoiding one unnecessary ER trip can cover months of membership.

If You’re on Medicare

Upper Echelon Medical has opted out of Medicare. Medicare beneficiaries can still become members, but they sign a private contract with the practice, and Medicare won’t pay for or reimburse UEM services. Your Medicare coverage for hospitals, specialists and other outside care stays the same. Ask our team for details before you enroll.

Five Questions to Ask Any DPC Practice (Including Us)

1. What exactly is included in the membership, and what costs extra?
2. How do I reach my physician, and how fast will I hear back?
3. What are your cash prices for labs, imaging and common medications?
4. How do you coordinate with specialists and my insurance?
5. What will membership plus my insurance premium cost over a full year?

Any practice worth joining should answer all five without hedging. We’ll give you the numbers in writing.

The Bottom Line

Insurance is for the catastrophes. Direct primary care is for everything that happens in between: the relationship, the access and the time to actually work through a problem. Used together, and paid for with HSA dollars where that’s allowed, they give you better care than either one alone.

If you’re in North Orange County and want to see whether it makes sense for you, book a meet-and-greet or call us at 657-212-3212. Bring your insurance card and your questions.

Sources

1. Upper Echelon Medical: Membership Pricing · FAQ
2. IRS Notice 2026-5 (HSA provisions of OBBBA, including direct primary care): irs.gov/irb/2026-02_IRB
3. Summary of the IRS DPC/HSA guidance: AAFP via LAFP