Medicare and Direct Primary Care: What Seniors in Portland, OR Need to Know

Introduction: What is Direct Primary Care?

As we age, having reliable and accessible healthcare becomes more important than ever. Many Medicare-eligible patients find themselves frustrated with long wait times, rushed visits, and unexpected costs. At PridePoint Health, we offer a different approach: direct primary care (DPC). This membership-based model allows patients to receive personalized, high-quality care without the interference of insurance companies, including Medicare.

A Great Insurance Plan Doesn't Always Mean Great Healthcare

Many people assume that having a comprehensive insurance plan means they will automatically receive high-quality healthcare. However, insurance-based models often come with long wait times, limited access to doctors, rushed visits, and excessive administrative hurdles.

Even with Medicare or a Medicare Advantage plan, patients can experience delayed care, denied services, or a lack of truly personalized attention. This is where Direct Primary Care (DPC) fills the gap—by prioritizing patient-doctor relationships, same-day or next-day visits, longer appointments, and a focus on preventive care. Instead of navigating through red tape, DPC members get direct, convenient, and high-quality healthcare without the hassle.

Understanding Medicare: Plans and Parts

Medicare is divided into different parts that cover various aspects of healthcare. Understanding these components can help you determine how direct primary care (DPC) fits into your overall healthcare plan.

Medicare Parts Explained

• Medicare Part A (Hospital Insurance):

  • Covers inpatient hospital stays, skilled nursing facilities, hospice care, and some home health care.

• Medicare Part B (Medical Insurance):

  • Covers outpatient care, doctor visits, preventive services, and some home health services.

• Medicare Part C (Medicare Advantage Plans):

  • Private insurance plans that bundle Parts A and B and often include extra benefits like vision, dental, and prescription drug coverage.

• Medicare Part D (Prescription Drug Coverage):

  • Provides prescription drug coverage through private insurance companies.

Can Medicare Patients Join a Direct Primary Care Practice?

Yes! PridePoint Health is now accepting Medicare patients, meaning you can sign up today and start receiving high-quality, patient-focused care. While Medicare does not reimburse for DPC memberships, many seniors still choose to supplement their Medicare coverage with a DPC membership for better access to their doctor, more personalized care, and fewer hassles.

While Medicare covers many healthcare services, it does not always provide the level of care and access patients need. This is where DPC can fill the gaps by offering longer visits, same-day or next-day availability, and direct communication with your doctor. Think of it as a way to enhance your healthcare experience while still using Medicare for hospital visits, specialists, and major medical expenses.

Medicare Advantage vs. Traditional Medicare with Supplemental Plans: Pros & Cons

Choosing between Medicare Advantage (Part C) and Original Medicare with a Supplemental Plan (Medigap) is an important decision, especially when considering how each pairs with Direct Primary Care (DPC).

Medicare Advantage Plans (Part C)

✅ Pros:

• Often includes additional benefits such as vision, dental, hearing, and prescription drug coverage.

• Can have lower monthly premiums, with some offering $0 premiums.

• Some plans offer out-of-pocket maximums, which help cap annual healthcare costs.

❌ Cons & Limitations:

• Network restrictions: Many Medicare Advantage plans require you to see in-network doctors and specialists, making it harder to pair with DPC providers who operate outside these networks.

• Referrals required: Some plans require referrals from a primary care doctor before seeing a specialist, adding an extra step for patients.

• Prior authorizations: Certain services require approval before coverage applies, delaying care.

• Higher costs when receiving care: While premiums may be low, Medicare Advantage plans often result in higher out-of-pocket costs when you actually need medical services, particularly for those with chronic or escalating health needs.

• Privately managed: These plans are run by private insurance companies, meaning coverage decisions can be based on financial incentives rather than patient needs.

🔹 How It Pairs with DPC:

• PPO (Preferred Provider Organization) Plans work better with DPC since they allow out-of-network care, making it easier to combine with a direct primary care membership.

• HMO (Health Maintenance Organization) Plans may not work well with DPC because they require in-network primary care providers.

Traditional Medicare (Parts A & B) with a Medigap Supplement

✅ Pros:

• No network restrictions: You can see any doctor or specialist who accepts Medicare, making it highly compatible with DPC memberships.

• No referrals needed: You can directly schedule specialist visits without requiring a referral.

• Predictable costs: Medigap plans help cover copays, deductibles, and coinsurance, reducing out-of-pocket expenses.

• Better for high healthcare needs: Although Medigap plans have higher premiums, they cover more services and limit unexpected costs, making them ideal for individuals who require frequent medical care.

❌ Cons & Limitations:

• Higher monthly premiums: Medigap plans generally cost more than Medicare Advantage plans.

• No extra benefits: Unlike Medicare Advantage, Medigap does not cover vision, dental, or prescription drugs, requiring a separate Part D plan.

🔹 How It Pairs with DPC:

• Medigap is a great option for DPC members because it covers hospital and specialist costs without restricting access, giving patients maximum flexibility.

• Patients can use DPC for routine and preventive care while using Medicare and Medigap for specialist visits and hospital stays.

Better Healthcare for Seniors in Portland, OR

At PridePoint Health, we believe healthcare should be personal, accessible, and hassle-free. Now that we are accepting Medicare patients, you can sign up today and start benefiting from direct, personalized care that puts you first.

📅 Interested in better healthcare without Medicare red tape? Sign up today!
📞 Call us at 503-616-2877 or visit our website to learn more!