The Coverage Conundrum: What Happens If Something Really Goes Wrong?

Even when people understand what Direct Primary Care is — better access, more time with your doctor, a real relationship with your physician — one question almost always follows:

But what happens if I have to go to the hospital?

It's the right question. DPC covers primary care beautifully. It does not cover surgeries, specialty drugs, emergency rooms, or catastrophic events. So when I started making plans to leave corporate medicine six months ago and gave up a robust employer-sponsored insurance plan for my family of five, I had to answer this question for myself — not just for my patients.

Here's what I found.

Option 1: COBRA — Familiar but Expensive

When you leave a job, you can keep your existing insurance through COBRA. You just pay your portion, your employer's portion, and a 2% administrative fee. In our case, that came to roughly $840 per family member per month — and our plan still carried a $6,000 annual deductible, meaning we'd spend that out of pocket before coverage kicked in. Out-of-network care — non-approved medications, independent therapists, out-of-network specialists — didn't even count toward that deductible.

Familiar, yes. Affordable, no.

Option 2: Health Sharing — Leaner and Surprisingly Solid

Health sharing is a model where members pool resources to cover each other's qualifying medical expenses. We found a company called Zion Healthshare that covers our entire family for catastrophic events for under $900 a month. There's an "initial unsharable amount" — essentially a deductible — of about $1,250 per covered event, capped at three times per year. After that, qualifying expenses are covered.

Combined with DPC memberships for our five family members, we're spending roughly half of what COBRA would have cost us — with significantly better day-to-day primary care access than we've ever had.

Option 3: Planstin — Health Sharing Plus an HSA

After discovering Zion, I found a company called Planstin that bundles health sharing with additional features to create an ACA-compliant plan — which means it qualifies you for a Health Savings Account.

An HSA is a tax shelter for healthcare dollars. A family can deposit a little over $8,000 per year, use those funds for DPC memberships and other qualified medical expenses, and pay zero taxes on that money. Anything unspent rolls over into an investment account that grows over time. For a few dollars less than $100 more per month than Zion alone, it's a genuinely compelling package.

For Employers: Planstin Goes Further

Planstin also builds employer plans. For companies with more than five employees, they can bundle specialty drug coverage and pre-existing condition coverage with DPC membership — for roughly the same price as the health share plus HSA option. It sounds too good to be true. It isn't.

What If You Already Have Employer Coverage?

Many people do — and some larger employers offer coverage for as little as $40 a month. That coverage is real and valuable for emergencies. But it doesn't mean you get to call your doctor. It doesn't prevent you from waiting weeks for an appointment just to ask a question that might have kept you out of the ER in the first place.

For those people, a DPC membership isn't a replacement — it's an upgrade. Direct physician access layered on top of existing coverage produces better outcomes, fewer unnecessary ER visits, and a care experience that actually feels like care.

The Bottom Line

If you're interested in Direct Primary Care but stuck on the coverage question, the answer isn't one-size-fits-all — it's a conversation. I can connect you directly with Zion Healthshare or Planstin depending on your situation, walk you through what makes sense for your family, and help you figure out whether DPC is the right fit.

If you're an employer, I'd love to talk about how to save money on the coverage you're already providing — while meaningfully upgrading the quality of care your employees actually receive.

📞 Call or text: 720-856-4058 ✉️ Email: DoctorJuan@metronomeMD.com 🔗 Book a free 10-min call: www.metronomemd.com