Breaking Free from Traditional Insurance: A Guide to Medical Cost Sharing & Direct Primary Care

What Is Medical Cost Sharing?

Medical cost sharing is a system where members contribute a set amount of money each month into a shared pool to help cover each other’s medical expenses, rather than paying premiums to a traditional health insurance company that would be for profit. It’s often organized through membership-based groups, typically with a common interest or shared values, such as health ministries, cooperatives, or other non-profit organizations. It has been most common in religious communities; however, in recent years, there have been new medical cost-sharing communities that have sprung up that are not religion-based.

In a medical cost-sharing arrangement, when a member incurs a qualifying medical expense, they submit it to the organization, which then distributes funds from the shared pool to help pay for the expense. Members generally pay out-of-pocket for smaller expenses, and the program helps with larger, often unexpected costs.

These programs usually have guidelines around eligible expenses and may not cover all treatments (e.g., preventive care or certain types of medications). Unlike traditional insurance, cost-sharing programs do not assume financial liability for members’ bills; instead, they rely on voluntary contributions.

What Is Direct Primary Care?

Direct Primary Care (DPC) is a healthcare model in which patients pay their primary care provider a flat monthly or annual fee directly for access to a range of primary care services. This fee typically covers most primary care needs, including office visits, lab work, and basic procedures, without the need for insurance billing. Patients pay their DPC provider directly, which removes the need for a middleman (like insurance) and allows providers to offer more personalized and accessible care.

Key features of DPC include:

• Flat Monthly or Annual Fee: Patients pay a predictable fee, usually between $20 and $150 per month, depending on the provider and level of care.
• Extended and More Personalized Appointments: DPC allows for longer, more in-depth visits, often 30 to 60 minutes or more, without the time pressure common in traditional practices.
• Easier Access to Providers: Many DPC practices offer same-day or next-day appointments, as well as options for communication via phone, text, or video, giving patients a closer relationship with their doctor.
• Reduced Administrative Burden: Since DPC practices don’t bill insurance, providers have less paperwork, which helps them focus more time and energy on patient care.

Direct Primary Care is typically used in combination with a high-deductible health plan or a medical cost-sharing program to cover major medical expenses, such as surgeries or hospital stays since DPC focuses on routine, preventive, and primary care.

Find a DPC provider here.

Quality of Care and Access

DPC will typically feel higher quality because of the more time your doctor will likely provide you. A brick-and-mortar DPC location is going to feel exactly the same as any other doctor visit. You will also find DPC establishments that are virtual or telehealth practices. Telehealth offices offer another option for folks and can benefit those living in rural areas. This option may take some getting used to. For instance, taking your vitals like blood pressure and pulse will need to be done at a pharmacy or investing $40 for a home device.  There are also some limitations that can’t be done virtually, such as a stethoscope on your back listening to your lungs. Telehealth DPCs will try to balance the limitations by having partners that can draw labs or provide other resources they can’t. 

Comparing Cost Sharing to Traditional Insurance

• There is not going to be a black-and-white answer to the question of whether medical cost-sharing or traditional insurance is more affordable. If we are talking about no employer-sponsored health insurance plan, then medical cost sharing is more than likely going to be more affordable than health insurance on the open market. The caveat to this is that we are talking about someone who doesn’t regularly take prescribed medications and has no major pre-existing medical issues.  
• Cost comparison, when compared with an employer-sponsored health insurance plan, depends on how good the plan is. For this author, I have had great health insurance through companies that would have been much cheaper than a medical cost-sharing program. At the same time, under my partner’s current employer plan, I save about half the cost with a medical sharing cost program. 

Look at the rates for all your options. Examine your health, history, and family’s needs. Consider any known future events, such as a pregnancy.

Learn more about how your health is tied to your wealth here.

Experience with Submitting and Receiving Reimbursements in Cost Sharing

If you’re a member of a medical cost-sharing community, then what? How does the reimbursement process work?

Once you understand the process and have done it once, you will be a master. Get comfortable submitting and receiving reimbursements with a medical cost-sharing community you’re a member of by testing the waters with a flu shot bill. It does take more work than going down the route of having regular medical insurance in some ways, but there can also be some work dealing with your insurance company as well.

This is how the process works. You have a health incident, and you receive a bill. You will make sure that the biller understands you are a cash patient, as health providers knock anywhere from 10%-30% when they don’t have to deal with insurance companies because of the time and cost it saves them. You will also need to ask for an itemized bill.

Then, you will upload the bill to your medical cost-sharing platform. Your medical coordinator will then process the bill and often send it to a third-party company that negotiates the bill on your behalf. You may be requested to provide additional information to see if you qualify for financial assistance. 

You will be notified after the negotiations are completed on your behalf. A member must pay an initial unshareable amount before the community pays to cover medical expenses it’s similar to a deductible. Once you pay your amount, your medical cost-sharing coordinator will release additional money to your bank account.  You must now pay the medical bill and submit the receipt showing proof to the medical cost sharer.

Tip: Stay organized with bills, keep a physical and digital folders with all bills and receipts that come in.

Organizing, calling to get itemized bills, and communicating with the medical cost-sharing provider does take effort. However, this is rewarded by saving you thousands of dollars in insurance premiums. 

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My Experience?

After going through a serious illness and being flown to a different hospital, I personally can get behind both alternative medical providers: medical cost sharing and direct primary care. I enjoyed my DPC provider more than the clinics I had access to with an insurance provider, but I was nervous about a major medical incident and how a medical cost-sharing community would support me.  Now that I have fully experienced the medical cost-sharing community during a major event and receiving community funds to pay the bills, I can say I am in full support and enjoy what it saves me in monthly premiums compared with a traditional insurance plan. I used the medical cost sharing plan provider Sedera because I am not that religious and many providers have some sort of religious aspect. My DPC is Bowtie Medical. Both of these companies did me justice and this is not an endorsement or promotion for them, but a means to share who my experience is with. 

Compare medical cost-sharing plans here.

Benefits and Pros of Medical Cost Sharing and Direct Primary Care Membership

It’s pretty awesome not paying co-payments when going to the doctor. Keep in mind that you do pay monthly membership fees.

-My primary doctor spends more quality time with me. It is more convenient for me to schedule a virtual check-up without having to drive anywhere.

-You are free to choose any hospitals or specialty clinics. No in-network or out-of-network situations. A side note is that in known upcoming treatments, for example, surgery, your MDS provider will want to help you research affordable options in order to share in reimbursement costs.  

-Saves me money, almost half the cost of the alternative option, traditional insurance coverage through my spouse’s work. However, maybe your employer’s medical insurance is really good, and your employer picks up most of the premium. 

Find out other ways to save money here.

Challenges and Drawbacks of Medical Cost Sharing and Direct Primary Care Membership

You have to pay for medicine directly out of pocket. A COVID booster shot was going to be $350 out of pocket. Now, to put things into perspective, I have received prescriptions to treat a sinus infection, an ear infection, and shingles. These medicines were between $15 and $80, not necessarily breaking the bank.

-You have a more limited number of businesses and doctors that operate direct primary care memberships.

-If you have a virtual DPC provider, you will forgo some physical examination aspects.

-An MDS community isn’t required by law to share costs with you and can deny sharing community funds with you. 

Final Thoughts

Navigating healthcare costs can feel overwhelming, but alternatives like medical cost-sharing and direct primary care offer a fresh approach that can save money while providing quality care. These options aren’t one-size-fits-all, but for many, they provide a more affordable and flexible way to handle medical expenses.

If you’re feeling unsure about which route to take, you don’t have to figure it out alone! At BlackBird Finance, I’m here to help you sort through the details and find the best fit for your healthcare and financial needs. Reach out anytime—I’d love to help you make a plan that works for you!

This article reflects the insights and opinions of its author and is not a recommendation or endorsement of their views or services.

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