Pairing Direct Primary Care With a High-Deductible Health Plan: A Patient's Guide

A direct primary care membership is a monthly or annual fee you pay directly to a primary care doctor or clinic. In return, you get unlimited or near-unlimited primary care visits, same-day or next-day appointments, phone and text access to your doctor, and often in-house labs or generic medications at cost. The membership is not insurance. It does not pay claims, it does not count toward a deductible, and it does not satisfy the Affordable Care Act requirement to carry minimum essential coverage.

A high-deductible health plan, or HDHP, is a type of insurance policy with lower monthly premiums and a higher deductible than traditional plans. The IRS sets minimum deductible thresholds each year to define what qualifies as an HDHP. For 2024, that threshold is $1,600 for self-only coverage and $3,200 for family coverage, according to IRS Publication 969. Once you meet your deductible, the plan pays for covered services like hospitalizations, specialist visits, imaging, and emergency care. HDHPs are available through employers, the ACA marketplace at HealthCare.gov, and directly from insurers.

Most people visit a doctor for routine, everyday reasons: a sinus infection, a blood pressure check, a skin rash, a prescription refill. A DPC membership covers that entire layer of care at a flat monthly fee. Because you are not running those visits through insurance, you are not paying copays, coinsurance, or surprise bills for each encounter. The American Academy of Family Physicians notes that DPC practices typically handle a wide range of primary care services within the membership, which can dramatically reduce the number of times you need to use your insurance at all.

That means you can pair your DPC membership with a lower-premium HDHP and essentially self-insure the gap between your DPC coverage and your deductible. If you stay healthy and your DPC doctor manages most of your needs, you may never reach your deductible in a given year. If something serious happens, such as a surgery, a hospitalization, or a specialist referral for a complex condition, your HDHP kicks in to protect you from catastrophic bills. Many patients find that the premium savings from choosing an HDHP over a traditional plan, combined with the DPC membership fee, still come out to less than what they would pay for a comprehensive low-deductible plan with copays.

A health savings account, or HSA, is a tax-advantaged account you can open when you are enrolled in a qualifying HDHP. Contributions are tax-deductible, growth is tax-free, and withdrawals for qualified medical expenses are also tax-free, according to IRS Publication 969. HSAs are a powerful tool for covering out-of-pocket costs under an HDHP. However, the IRS has issued guidance that creates a complication for DPC members who also want an HSA.

Under current IRS rules, a DPC membership fee is generally not considered a qualifying medical expense for HSA purposes, and more importantly, having a DPC membership may disqualify you from contributing to an HSA if the membership is structured in a way that provides medical benefits before your deductible is met. The IRS addressed this in Notice 2023-37, clarifying that certain arrangements can affect HSA eligibility. The rules in this area are nuanced and have been subject to ongoing legislative discussion. Before you open or contribute to an HSA while holding a DPC membership, speak with a tax professional or benefits advisor who is familiar with current IRS guidance. Do not rely on this article as tax advice.

DPC practices vary, so you should always ask a specific practice for a written list of what is included in the membership. That said, most DPC memberships cover primary care visits with no per-visit fee, preventive care screenings, chronic disease management for conditions like diabetes or hypertension, minor procedures such as wound care or joint injections, and sometimes deeply discounted labs or generic medications. Some practices also include telehealth visits, mental health check-ins, and care coordination with specialists.

What DPC does not cover is equally important to understand. It does not cover hospitalizations, emergency room visits, surgeries, specialist consultations billed outside the practice, advanced imaging like MRIs or CT scans, or prescription drugs dispensed at a pharmacy. Those costs flow through your insurance plan or come out of pocket. This is why pairing DPC with at least a catastrophic or HDHP-level insurance plan is strongly recommended for most patients. Going without any insurance at all leaves you exposed to potentially life-altering medical bills.

Not all HDHPs are the same. When comparing plans, look at the annual premium, the deductible, the out-of-pocket maximum, the network of hospitals and specialists, and whether the plan covers out-of-network emergency care. The out-of-pocket maximum is especially important because it caps your total exposure in a bad year. For 2024, the IRS sets the HDHP out-of-pocket maximum at $8,050 for self-only coverage and $16,100 for family coverage. You can compare ACA marketplace HDHP options at HealthCare.gov during open enrollment or a special enrollment period.

If you are self-employed or your employer does not offer group coverage, the ACA marketplace is your primary option for individual HDHP coverage. Premium tax credits may be available depending on your income, which can make an HDHP even more affordable. If you have access to employer-sponsored coverage, ask your HR department whether any of the offered plans qualify as HDHPs and whether the employer contributes to an HSA on your behalf. Employer HSA contributions are a meaningful benefit that can offset your out-of-pocket costs.

Start by estimating your typical annual healthcare use. If you see a primary care doctor a few times a year, take a few maintenance medications, and rarely need specialist care, the DPC plus HDHP model is likely to work well for you. If you have a complex chronic condition that requires frequent specialist visits, high-cost medications, or regular imaging, run the numbers carefully. Your DPC doctor can still manage your primary care, but your insurance costs may be higher because you will likely hit your deductible most years.

Next, contact DPC practices in your area and ask for a written list of what the membership includes, the monthly fee, and whether they have any position on HSA compatibility. Then compare HDHP options through your employer or HealthCare.gov. Add up the annual DPC membership cost plus the annual HDHP premium, and compare that total to the annual premium of a traditional plan you might otherwise choose. Factor in the average copays and coinsurance you would pay under the traditional plan. That comparison will give you a clearer picture of whether the DPC plus HDHP strategy makes financial sense for your situation.

DirectMedicine is a directory of direct-pay, cash-pay, and direct primary care doctors across the United States. When you are researching the DPC plus HDHP strategy, one of the first things you need is a clear picture of what DPC practices in your area actually offer and what they charge. DirectMedicine lists practices with transparent information so you can compare memberships, services, and fees without having to call a dozen offices.

You can use DirectMedicine to find DPC practices near you, review what each practice includes in its membership, and identify providers who are a good fit for your health needs and budget. Once you have a shortlist of practices, you can reach out directly to ask the specific questions that matter for your situation, including how the practice handles referrals, whether they offer discounted labs, and how they coordinate with your insurance for services outside the membership. Transparent information up front helps you make a confident decision before you sign up for anything.