Frequently Asked Questions

Is hospitalization covered on the MEC plans?


NO. We have plans that do. If they like DPC and want hospitalization as well, those plans range from $450 to $750 PEPM depending on the group. The stop loss on those is not fixed. We must send the group to the INSURANCE company for them to set the risk Premium. That is variable depending on the health and demographics of the group. These MEC plans are the basic plans that are plug and play and easy enough to sell you can do it yourself with or without a sales partner like a broker.




Is this considered insurance plan?


Yes, these are all ACA compliant Self-funded Insurance plan




Would I be paid by MyMD Connect or the employer?


MyMD Connect




As a practitioner, would I be responsible for any administrative fees?


No




What do I have to do to host MyMD Connect DPC based plans in my practice?


There is a bit to learn to do the plan DPC management and be valuable. There is no cost to the DPC from MyMD Connect. There are platforms that must be used to do the MyMD Connect plans. HINT Elation Spruce are requirements for the foreseeable future. Reason is the data programing that I have done out of those integrated platforms with MyMD Connect and the various vendors and administrators. We also assist the DPC doc in these platforms on a day to day basis. I do not have a financial relationship with them.




Does MyMD Connect work with certain medication distributors?


We work with Southern Scripts. One of the few transparent TPAs. If you can dispense in your clinic you may do so if the cost is less that the $20 co-pay. The patient just buys from you. That is the ideal way, but few states do not allow this. [TX]. The plan cannot cost more than the monthly cost because we have Excess Loss on the risk areas within the plan. The plans do have a setup fee the administrator charges to set up the plan docs, do the enrollment and establish the trust and trust account that houses the plan, also file the annual required Tax forms for the employer plan. It is a onetime a year fee and is around $750.




For the Concierge lab/radiology/advanced imaging, are there certain companies that the plans are contracted with?


Yes. But you should be able to source imaging and labs with your clinic, with any company for your patients. If that amount is compliant with what the plan is willing to spend then you can source it and we will bill the plan for your reimbursement. MyMD Connect has these types of contracts as well and we can source all your imaging and labs for you if you like. The advantage to that is you would not have to front the $s. [The plan budget is always higher than a DPCs cost on things BTW. If not, you need better pricing.]




Is there a required EMR?


We are fully integrated with Elation Health. We will also accept Cerbo by MD HQ. If your practice is not run on either of these platforms you can contact us to check compatibility of your current EMR and MyMD Connect.




What are examples of DPC related diagnostic tests?


At home sleep studies, Labs, X-ray, US, In-office rapid testing




When you say that I can start selling the plans myself, what exactly do you mean?


You can explain the plan types and direct the employers to us for completion.




Can they opt into at any time, as today or wait until open enrollment usually in Jan?


Yes, you can opt in at any time.




Does the employer have to pay for the entire health plan or can employee pay for a portion?


We like the employer to pay for most or all of it so that we get high participation in the plan offering. There are minimum sizes the group must hit as well. So, the employer portion usually needs to be large enough to hit those levels. But any arrangement can be chosen. The portion the employee pays is set up through payroll deduction.




Assuming an employee is on MEC "Plan 3": Suppose they are a diabetic, and need to be on insulin (let's just say Levemir and Novolog), is that considered "not covered"?


That is a Branded drug. These 3 MEC plans do not cover Branded drugs. [we have more expensive plans that do, but these are the 3 most basic plans that do not have the complexity that would prevent us from getting a fixed rate on the Excess Loss Policy for the employer. As the DPC doc you would be able to source the needed drug. Either patient assistance, which for the blue-collar folks that are usually on these plans that is not hard. For those that do not qualify we can issue a MyMD Connect Rx card that will activate any manufacturer coupon to get the large discount on the card for the branded drug. [Ideally you get patients off insulin]




"Includes Excess Loss Coverage" -- does that mean there is a deductible they could hit and after that amount it's covered as well?


There is no deductible to hit that changes the coverage listed. Now, there is an out of pocket maximum that every ACA compliant plan in the nation has set by law. If they hit that level with covered expenses, then the plan has to pay for all covered items for the rest of the plan year. This would never happen on these plans. The Excess Loss Coverage is a Stop Loss policy for the owner of the health plan so that his cost does not exceed the listed pricing. If the plan runs a higher expense than what has been built in to pay for expected claims, then the INSURANCE company pays the rest of the claims not the employer. Has nothing to do with the patients.




Should I also advise the employer to encourage employees to have some sort of catastrophic insurance in the case of an accident that would render them requiring multiple scans, surgeries, etc?


Yes. As the DPC doc you should council all patients on what kind of catastrophic coverage would be best for them. That ranges from none, to health sharing, to exchange policy to their spouse's employer plan, to Indemnity type plans for Accident, hospital, cancer etc..... These plans are to provide the tools to get most medical care from you the DPC doc. That is all paid for. We would love for in addition to these plans the employer to help pay for some type of additional coverage. See types above. This can be done through an HRA. This gets complex, but we can set those things up if desired. The last 1800 man group we sold, bought a virtual MEC plan. They paid 100% of the employee cost. Then they are contributing 150$ a month to an HRA for them to use how they see fit to cover cost that the plan does not cover.




Do I need to be opted out of Medicare?


No [but you should]




For XYZ Group, for example, it sounded like a total of 82 lives and $ 1300 is paid to the dpc doctor monthly which comes out to about $16 per life per month. Is this just such a low cost because it is only virtual?


Yes virtual rates are as following for the DPC doc on all our plans. EE [employee only] $20 PEPM [per employee per month]; ES [employee spouse] EF [Employee Family] EC [Employ and children] all 3 pay $40 PEPM. Virtual is lowest cost plan and used for remote management only. Our complete plans which have your office included pay twice that. These are the price points we know we can sell. If the DPC doc wants to sell the plans for more, they are welcome to. The higher DPC component of the total price goes up by the exact amount to the employer. When we look at the utilization with in our very happy groups it runs 30 to 40% of what your individual patient utilizes you. So, per utilizing member, these rates are our highest revenue patients.




When my practice opens in the near future and am hoping to get my own small business accounts in the area. Which this is obviously what I am more interested in learning the breakdown of payment and responsibilities on each party. -Would I set up my fees? For example, $50 a month for each employee and maybe discounted rates for family members from my individual fees? Or is there already a fixed amount through MyMD Connect?


Again, this is for everyone on the health plan not just those using you, which they will not.




Would each employee sign my patient agreement contract?


No. We have them sign a contract and HIPAA form prior to using you. The contracting is done at the health plan level not the patient level.




Which outlines what I will and will not do including chronic pain medication etc?


We do not do Narcs or Benzos period. The employers are told this so there are no expectations otherwise. You are the Doctor therefore you practice the way you want.




If I had an issue with a patient and did not want to take care of them due to a violation of patient contract etc. does the employer just pay back the employee that $50 a month?


No. They just do not get to come see you. We would try to move them to another vendor with MyMD Connect to try to resolve. But the employer pays for the health plan for the whole year. There can be no changes during the year if someone can't come see you or chooses not to.




I have watched a lot of videos and I know you are trying to bring business and support DPC doctors without taking a cut, but I am just trying to figure out the logistics and how MyMD Connect makes a profit.


Eventually MyMD Connect should make a profit.We design and sell health plans to employers that harness DPC skill! We get paid in the health plan Administration which is part of the million pieces of the health plans. The more efficient we get at that the more likely we are to make $.
Now recall that I am a DPC doc with my own practice that is a Vendor for MyMD Connect. That is how I benefit now from all this work. My practice gets half of its revenues from providing DPC to these health plans. I can sell these plans without problem.




What physician network is used for plans 2 and 3?


We do not like Networks! We use open access plans where the patients can see any doctor of their choosing. The plans pay doctors more than PPOs and doctors are happy to see the patients. Currently we do add an outpatient PPO First Health network, but you are not limited to that network.




What pharmacies are in network?


http://www.southernscripts.net/network-pharmacy-locator.php

Southern Scripts Pharmacy Benefit Manager

www.southernscripts.netSouthern Scripts a unique PBM model with three core components. Our goal is to provide employers with the right tools to achieve optimal health outcomes for their members by providing ideal access for prescription medications. Very few are not in the Rx network
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Is it determined somewhere what the DPC portion needs to include? Is it just what I normally include in my membership plans?


The services are exactly what your membership plans include. You treat them these patients the same.




As a practicioner how much would I be getting per patient?


$45 [PEPM] for employee only[EE}, $85 Employee Spouse[ES],$75 Employee Child[EC], $110 Employee Family[EF] for brick and Mortar patients. $20 EE and $40 for ES, EC, EF. This is our standard pricing. If the employer is willing to pay higher or lower rate the DPC allocation can be changed. The market has shown us this pricing is best.$45 per member per month.




I am an internist and see patients 16 and above, how will that work with family plans?


You can only do what you are able to do. We have IM docs that do fine. The employer or buyer must understand that is the case. In most cases finding a local Pedi doc to refer to is fine. Employer may push back on the price a bit because of this care gap.




Patients may ask, “Working with you, do all my visits and treatment get applied to my deductible as they normally would?”


Yes and No. What I do to help you is Free or for a co-pay, so not applicable for your deductible. When you see other doctors, it would apply. We are here to help you and give you advice.
Think of us as an inside the system friend that can guide you around the pain points of the broken medical system. We are here to help you around the holes in the system. Most other health plans are dreadful!




Is there a website the other provider can go to "see that it's legit" when handed the plan card?


Yes, and an 800 number for them to verify the patients benefits.




Are childhood vaccines covered? If so, how would I be reimbursed if giving immunizations in my office?


The plans reimburse you for the immunizations.




Can this be offered to employers in different states, i.e. NY or NJ?


Yes. 48 states we have no restrictions. In those that have restrictions we simply set the self-funded trust plan up that houses the health plan here in Texas which allows any business in any state to offer our plans.




Do the MEC health plans get employers out of the penalty?


Yes, the MEC health plans get the employers out the 49-80 HA plenalty, also known as the Sledge Hammer Penalty. The Sledge Hammer Penalty is an automatic $2,000 fine multiplied by the number of full-time employees for not offering any ACA compliant health plan.





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