New Healthcare Models Beyond the ACA: What They Are, What They Solve, and What They Don’t

When people feel uncertain about ACA coverage, they often look at “alternatives.” Some are real care models (like concierge medicine and direct primary care). Others are financial products that are not insurance. This article explains the major categories, how they fit together, and how to avoid gaps that can surprise families. Educational only; not legal, tax, or medical advice.

If you’re anxious about health insurance changes, you’re in good company. Many people aren’t looking for “something fancy.” They’re looking for something stable: clear access, honest guidance, and fewer unpleasant surprises.

Here’s the key truth that clears up most confusion:
Insurance is financial protection.
Primary care models are how you experience care day to day.

You often need both.

If you’re exploring a membership-based primary care relationship in Colorado, The Cove Concierge Medicine is built around time, continuity, and coordination. Start here: Cove Membership.

Model 1: Concierge Medicine (an access and relationship model)
Concierge medicine is typically a membership-based relationship with a physician or practice. You pay a membership fee for enhanced access and services defined by the practice.

Important Medicare note: Medicare.gov states you pay 100% of the membership fee for concierge care, and Medicare doesn’t cover membership fees.

What concierge medicine can do well

·         Improve access (shorter waits, longer visits)

·         Create continuity (a stable relationship with your care team)

·         Coordinate care across a complex system (referrals, records, follow-through)

What concierge medicine does not do

·         It is not major medical insurance

·         It does not pay hospital bills, surgeries, or specialty care costs

If you want to understand how concierge membership would fit with your current plan, schedule a Meet + Greet: www.thecovecm.com/contact.

Model 2: Direct Primary Care (DPC) (a defined primary care package, often outside insurance)
DPC is another membership-style primary care model. The American Academy of Family Physicians describes key features of DPC as charging a periodic fee for a defined set of primary care services and not billing third parties fee-for-service for those services covered by the periodic fee.

People often compare concierge and DPC. The simplest distinction:

·         Concierge practices may still bill insurance for covered medical services, depending on the practice.

·         DPC practices typically operate outside insurance for the defined primary care package.

Either way, neither is a substitute for major medical insurance when large costs arise.

Model 3: Individual Coverage HRA (ICHRA) (an employer reimbursement approach)
If you’re employed (especially by a small or mid-sized organization), a growing structure is the Individual Coverage Health Reimbursement Arrangement (HRA), also called an individual coverage HRA.

HealthCare.gov explains an individual coverage HRA allows employers to reimburse employees (tax-free) for qualified medical expenses up to a set annual amount, including monthly premiums and out-of-pocket costs, without offering traditional group coverage. To use the funds, employees must have their own individual health insurance plan (like one from the Marketplace).

This is not a health plan by itself; it’s a way to pay for one.

Model 4: Short-term limited-duration insurance (STLDI) (temporary coverage with limitations)
Short-term plans are often marketed as lower-cost alternatives. CMS explains that the federal definition has been amended to limit STLDI to an initial contract term of no more than three months and a maximum coverage period of no more than four months, including renewals or extensions.

Short-term coverage can be useful as a bridge in certain situations, but it is not designed to function like ACA-compliant major medical coverage. You should assume it may have different rules and protections than Marketplace plans.

Model 5: Health care sharing ministries, discount plans, and “risk-sharing” products (not insurance)
The NAIC warns that health care sharing ministries may provide limited to minimal benefits and pose risks because they are not regulated like insurance. These products may not offer the protections families expect when they hear the word “coverage.”

If you take only one thing from this article, let it be this:
If it’s not insurance, do not expect insurance protections.

The stability strategy: pair financial protection with real access
Many families find the most stable approach looks like this:

·         Keep or obtain major medical insurance (Marketplace, employer plan, Medicare, Medicaid/CHIP)

·         Add a stable primary care model that gives you time, continuity, and coordination

If you’re tired of feeling rushed and want a primary care home designed for clarity and follow-through, explore The Cove Concierge Medicine: The Cove CM Meet & Greet.

Educational only; not legal, tax, or medical advice.