Medicare, Direct Primary Care, and the Rules No One Explains Clearly
One of the most misunderstood topics in Direct Primary Care is how DPC physicians interact with Medicare. Not because it’s shady. Not because it’s forbidden. But because the rules were written for a healthcare system that no longer exists. So let’s talk about it clearly. First: The Big Picture Medicare was designed around insurance billing. Direct Primary Care is designed around direct relationships. Those two models don’t naturally fit together—which is why Medicare has specific rules about how physicians can participate, opt out, or limit what they provide. Understanding those rules is critical—for doctors and patients. The Core Medicare Rule That Matters A physician who is enrolled in Medicare cannot charge Medicare beneficiaries cash for services that are otherwise covered by Medicare. That’s the foundation of the entire framework. From that single rule, everything else flows. The Two Legitimate Paths for a DPC Physician 1. Opt Out of Medicare A physician formally opts out and enters into private contracts with Medicare beneficiaries. - The physician does not bill Medicare - The patient agrees not to seek Medicare reimbursement - The relationship is entirely private - The opt-out lasts 2 years at a time This path is legal, structured, and commonly misunderstood. 2. Remain Enrolled, But Limit Scope A physician stays enrolled in Medicare but does not charge Medicare patients for covered services. - Medicare-covered services must be billed to Medicare - Non-covered services may be offered privately - Membership fees must be carefully structured - Boundaries must be extremely clear This path requires discipline and precise compliance. Why the Rules Feel So Rigid Medicare is designed to: - Prevent double billing - Protect beneficiaries from coercion - Maintain standardized coverage What it is not designed to do is accommodate innovative care models. So the rules aren’t malicious—they’re just outdated. Common Scenario Questions (And How DPC Doctors Stay Compliant)