DPC or concierge: the fork is what you do with insurance, not what you charge

What separates the two models

The insurance posture separates them. A direct primary care practice takes a periodic fee from the patient and sends no claim to an insurer for the primary care that fee covers. A concierge practice takes a retainer for non-medical services and amenities and keeps billing insurance for the medical services underneath it. Price, panel size and the word on the door follow from that choice or fail to sort the two at all.

Washington put the posture in the definition. Chapter 48.150 RCW describes a direct practice as one that does not accept payment for a direct patient's health care services from any entity regulated under Title 48, the state's insurance code 1Ref 1Washington State Legislature (2013).RCW 48.150.010 — Definitions (Chapter 48.150 RCW: Direct Patient-Provider Primary Health Care).That Washington's direct practice definition makes non-billing definitional: the practice does not accept payment for a direct patient's health care services from any entity regulated under Title 48, the state's insurance title.. Not accepting an insurer's payment is definitional there. A practice paid by a Title 48 entity for a direct patient's care falls outside the definition. That is Washington's text, binding in Washington, and every state that has legislated here wrote its own.

Texas arrived at the same posture from the other direction. Its direct primary care sections, codified at Tex. Occ. Code sections 162.251 to 162.256, say a physician providing direct primary care is not an insurer or a health maintenance organization, and that the medical service agreement is not health or accident insurance or coverage under Title 8 of the state Insurance Code 2Ref 2Texas Legislature, 84th Regular Session (2015).H.B. No. 1945 — An Act Relating to the Provision of Direct Primary Care (enrolled bill text; codified as Tex. Occ. Code ch. 162, subch. F, §§162.251–162.256).That a second state takes the same not-insurance posture (a direct primary care physician is not an insurer or HMO, and the medical service agreement is not insurance under the state Insurance Code), and that its definition of direct fee is broad enough to cover several fee structures, so the fee shape does not identify the model.. The same act defines direct fee broadly, as a fee charged by a physician to a patient or a patient's designee for primary medical care services, and says the term includes a fee in any form: a monthly retainer, a membership fee, a subscription fee, a fee paid under a medical service agreement, or a fee for a service, visit or episode of care.

So the shape of the fee sorts nothing, and a monthly membership can sit on either side of the fork.

What a concierge retainer may charge for

Special non-medical services and amenities, kept on their own line. The AMA Code of Medical Ethics, current version, tells a retainer physician that contracting with individual patients for such services is permitted when patients pay out of pocket, that those charges must be clearly distinguished from medical services reimbursable by insurance or another third-party payer, and that a patient who declines the retainer keeps being treated under their existing insurance 3Ref 3American Medical Association, Council on Ethical and Judicial Affairs (2026).Opinion 11.2.5 Retainer Practices.The concierge half of the fork at the ethics-guidance level: a retainer may cover special non-medical services and amenities paid out of pocket, those charges must be kept clearly distinct from medical services reimbursable by insurance or another third-party payer, and a patient who declines the retainer continues to be treated under existing insurance. Cited as the Code's current version, with no year asserted, and identified in prose as ethics guidance rather than law..

That opinion is professional ethics guidance and carries no penalty of its own. The compliance question underneath it belongs to the payer contract and to the federal program rules, which are the documents that say whether a particular fee duplicates something an insurer already pays for. Ethics guidance states the separation principle, and the contract states what happens when the separation fails.

A concierge practice keeps every piece of apparatus a claims practice keeps. Coding, eligibility checks, denials work and your fee schedule all stay in the week, because the medical services under the retainer still go out as claims. The retainer adds a second ledger beside that work rather than replacing any of it.

Medicare runs on its own rules for both models

Medicare has a named federal mechanism for private payment, and a retainer written in a practice's own words does not create one. Billing a Medicare beneficiary outside the program runs through the private contract and opt-out rules at 42 CFR Part 405, Subpart D, which set out the affidavit, the private contract itself, what opting out does, what happens when an opt-out is not maintained, and how one is cancelled 4Ref 4Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR Part 405, Subpart D — Private Contracts (§§405.400–405.455: definitions, opt-out conditions, the affidavit, effects of opting out, failure to maintain opt-out, cancellation).That private payment by a Medicare beneficiary runs through a distinct, named federal mechanism with its own affidavit, private contract, opt-out effects, failure-to-maintain and cancellation sections, rather than through a retainer a practice writes for itself. No duration or renewal figure is taken from it..

Read the subpart's opt-out conditions and cancellation sections, or your MAC's published private-contracting guidance, before a Medicare beneficiary pays anything outside the program.

But the question reaches a direct primary care practice too, before the first membership is sold. What a membership fee may cover for a Medicare beneficiary comes from the subpart and from counsel who has read the practice's own agreement, not from the name of the model.

The not-insurance exemption belongs to your state

Your state grants it, and it grants it on conditions. Arizona Revised Statutes section 44-1799.92 requires a direct primary care agreement to be in writing, to be signed, to describe the scope of services, to state the periodic fee and any additional fees, to set duration and renewal, to allow termination on 30 days' notice with separate terms for relocation and military duty, and to carry a prescribed disclaimer that the agreement is not health insurance 5Ref 5Arizona State Legislature (2025).44-1799.92. Direct primary care agreements; requirements; notice.The seven-element required-terms list for an Arizona direct primary care agreement (writing and signature, scope of services, periodic and additional fees, duration and renewal, 30-day termination with relocation and military-duty terms, and the prescribed not-insurance disclaimer), presented as Arizona's list only..

Utah asks for three things and files them under a different name. Utah Code section 31A-4-106.5 governs what it calls a medical retainer agreement, and requires the agreement to describe the specific routine health care services covered, to state prominently and in writing that it is not health insurance, and to prohibit the provider from billing an insurer for those services while leaving the patient free to do so 6Ref 6Utah State Legislature (2012).31A-4-106.5. Medical retainer agreements.The contrast case for state variation: Utah's three-element medical retainer agreement (describe the specific routine services covered, state prominently in writing that it is not health insurance, prohibit the provider but not the patient from billing an insurer), and the naming difference that makes a search on direct primary care fail in Utah..

The required-terms list is your state's, and the two lists on this page do not agree: Arizona enumerates seven elements, Utah three. The four chapters do not even sit in the same body of law: Washington's is in the insurance title, Texas's in the occupations code, Arizona's in a trade and commerce title, Utah's in the insurance code.

That spread makes the search harder than it looks. A clinician searching their own code for direct primary care can come up empty in Utah, because the phrase there is medical retainer agreement. Search your own state's code by the fee word rather than the model name, and read the required-terms list before anyone drafts the direct agreement, so the draft starts from the statute.

The federal HSA ceiling on a direct primary care fee

Whether DPC fees and the HSA can coexist now has a federal answer with a number attached. Public Law 119-21 amended 26 U.S.C. 223 to define a direct primary care service arrangement and to disregard it as a health plan for HSA purposes only while the fee stays at or below $150 a month for one individual, or twice that for an arrangement covering more than one person, for months beginning after December 31, 2025 7Ref 7United States Congress (2025).Public Law 119-21, "One Big Beautiful Bill Act" (H.R. 1) — Sec. 71308, Treatment of Direct Primary Care Service Arrangements (139 Stat. 326-327).The federal definition of a direct primary care service arrangement added to 26 U.S.C. 223, the $150 per month ceiling for one individual and twice that for an arrangement covering more than one person, the effective date for months beginning after December 31, 2025, and the three service types excluded from primary care services for that purpose..

The same definition carves three things out of primary care services for this purpose: procedures requiring general anesthesia, prescription drugs other than vaccines, and laboratory services not typically administered in an ambulatory primary care setting 7Ref 7United States Congress (2025).Public Law 119-21, "One Big Beautiful Bill Act" (H.R. 1) — Sec. 71308, Treatment of Direct Primary Care Service Arrangements (139 Stat. 326-327).The federal definition of a direct primary care service arrangement added to 26 U.S.C. 223, the $150 per month ceiling for one individual and twice that for an arrangement covering more than one person, the effective date for months beginning after December 31, 2025, and the three service types excluded from primary care services for that purpose.. A membership that bundles any of them can lose the treatment even when the monthly figure clears the ceiling.

But the ceiling is a tax rule about eligibility and sets no limit on what a practice may charge. A practice above the line keeps its fee, and its patients lose the disregard, which matters most on a panel built out of high-deductible plans. The figure comes from the amended statute. A taxpayer-facing IRS publication may not yet reflect it, so read section 223 with your CPA before you price around it.

What each model asks of the practice

Each model asks for a different back office. Direct primary care removes claims work and puts the revenue line on panel size multiplied by monthly fee, which is the DPC equation and close to the whole of it. Concierge keeps the claims apparatus and adds a retainer ledger beside it, so the practice runs two collection systems and answers for the boundary between them every month.

Dropping claims does not retire the identifiers. Laboratories, imaging centers and pharmacies commonly want an ordering clinician's number on the order, referrals route on it, and the split between NPI-1 and NPI-2 still decides whether the person or the entity appears. A practice that stops billing insurers keeps those registrations current anyway.

Run the arithmetic before the name. Write down the panel you can hold and the fee you would charge, then write down what you would still bill and to whom, and check that fee against the federal ceiling while both lists are in front of you. The paperwork follows from the two lists: a written direct agreement built from your state's required terms in one model, a retainer contract and a maintained claims workflow in the other.