Frequently Asked Questions

DPC membership includes, at no extra cost:

• Extended, relaxed visits with your doctor: Each appointment allows time for thorough discussions, ensuring every one of your questions is addressed. Our approach emphasizes the cultivation of a personalized healthcare relationship!
• Same Day or Next Day Appointments for Urgent Needs: Because of the administrative burdens DPC removes, we have more time to spend with patients. You are the primary focus.
  Unlimited in-office and telehealth (video, email, text) access to your provider: Your communication preferences are accommodated to the fullest extent, and we are always here to answer questions.
• Care navigation: Your DPC and Nudge Health will work with you to ensure that any additional medical needs—from labs to imaging to specialist visits—are scheduled seamlessly and in a way that meets your cost and insurance preferences.
• An annual physical: This exam will be tailored to your individual medical requirements, centered on achieving your wellness objectives.
  Basic blood panel, pap smear, and EKG: Included for no extra charge with your annual physical is a basic metabolic blood panel, pap smear, and EKG test. All of these procedures are conducted in the comfort of our office.
• Exclusive discounts on additional diagnostics and immunizations: For the lab and diagnostic services not included in your membership (flu and COVID vaccines, complex labs, ultrasounds, x-rays), we have secured discounted, cash pricing exclusive to our practice and patients.

Dentists affiliated with Nudge Health DPC modeled care are paid a monthly subscription fee that includes two comprehensive evaluation, two x-rays (one panoramic x-ray and one FMX a set of full mouth x-rays), and two cleanings (either two prophylaxis, or one full mouth debridement and one prophylaxis) per year at zero additional cost. Any other procedures would be out of pocket fee for service at a negotiated rate equal to Delta Dental of Illinois 2024 in-network fee schedule. This resulting in less costly prices for procedures and transparent prices for you that result in less overall cost to a treatment plan by dentist than if you had dental insurance, including deductibles and copays based on a $1,500-$2,000 maximum benefit amount. 

Full access to psychiatric and mental services care that include in-person and telehealth consultation. 

Yes, we work directly with a Pharmacy Benefits Manager (PBM) to source medications at the best price for our patients at no additional cost. Soon, there will be a pharmacy DPC option as well, where you will have access to transparent drug pricing that stays fixed and at cost to the pharmacist throughout the year with a reimbursement from the insurance plans or HealthShare options you add to your coverage. 

Our pediatric care program is dedicated to supporting children’s health, growth, and happiness at every stage of development. From routine check-ups and developmental screenings to nutrition and behavioral support, our program is designed to help children thrive, ensuring a healthy, joyful childhood in a caring environment.

By bypassing insurance billing, DPC modeled wellness plans allow doctors to spend less time on paperwork and more time focused on patient care, enhancing the quality and attentiveness of each visit.

At Nudge Health we partnered up with GoodBill at no extra cost to our clients to help contain the cost of hospital and urgent care bills. 

GoodBill is a healthcare startup focused on helping patients lower their hospital bills by auditing charges for errors, identifying pricing discrepancies, and negotiating with hospitals on their behalf. Their services leverage new regulations, such as the Hospital Price Transparency Rule, which requires hospitals to disclose service rates, to ensure that patients are billed fairly. Users simply upload their billing information, and GoodBill’s software and medical experts review it for potential savings, which they then negotiate with the hospital.

The company’s mission is to simplify and demystify the billing process in a healthcare system that often lacks transparency, offering patients data-driven tools and support to lower healthcare expenses​.

To compare Philadelphia American Life Insurance Company's Indemnity Benefit Policy (Form H-0434) with United Healthcare’s Fixed Benefit Health Insurance (Health ProtectorGuard, HPG), here are key points that outline similarities and differences across coverage, flexibility, premiums, and suitability:

1. Policy Structure and Purpose

• Philadelphia American (Indemnity Benefit): An indemnity plan with set benefits per incident or service, paying directly to the policyholder to cover medical or personal costs. It is primarily supplemental, not comprehensive.
• United Healthcare (HPG): A fixed-benefit policy that provides cash benefits for specific medical services (e.g., doctor visits, hospital stays), also paying predetermined amounts that don’t adjust to actual costs.

Similarity: Both provide fixed payouts, helping to offset medical expenses but not intended to cover all costs comprehensively.

2. Flexibility and Coverage Use

• Philadelphia American: Offers flexibility, with policyholders free to use funds for various expenses. It's generally used to supplement other coverage.
• United Healthcare (HPG): Allows benefits to be used flexibly, often filling gaps left by high-deductible health plans. It may serve as a limited primary or supplemental coverage depending on the user’s needs.

Similarity: Both plans allow flexible use of benefits, making them valuable as gap coverage for expenses beyond traditional health insurance.

3. Benefit Amounts and Payouts

• Philadelphia American: Provides preset benefit amounts by incident type (e.g., inpatient vs. outpatient), covering a range of services but with limits.
• United Healthcare (HPG): Also offers fixed payouts per service, with clearly defined caps, so patients may still owe additional costs if expenses exceed the benefit.

Similarity: Both have capped payouts, requiring policyholders to manage potential out-of-pocket costs for expenses above the fixed benefit.

4. Premiums and Cost Structure

• Philadelphia American: Has lower premiums than major medical plans, making it affordable as a supplemental plan. Policyholders must be mindful of coverage gaps.
• United Healthcare (HPG): Offers budget-friendly premiums, lower than full insurance plans, appealing to those seeking cost control while avoiding high deductibles.

Similarity: Both are designed to be more affordable than comprehensive health plans, appealing to those who prioritize lower costs over full medical coverage.

5. Suitability and Ideal Policyholders

• Philadelphia American: Suitable for individuals wanting affordable supplemental coverage, especially those with high-deductible plans or Medicare. It’s ideal for those who can manage limited out-of-pocket costs.
• United Healthcare (HPG): Appeals to younger or self-employed individuals without high medical needs, providing predictable support for out-of-pocket expenses alongside a high-deductible plan.

Similarity: Both cater to individuals looking for partial or supplemental coverage, particularly useful for those who don’t require full insurance but want some financial support for medical events.

In Conclusion

Both plans target individuals seeking structured, affordable support for medical expenses, either as a supplement or a limited substitute for primary health insurance. Choosing between them depends on the desired flexibility, budget, and level of health expense management.

Philadelphia American Indemnity Benefit Policy (Form H-0434):

• Pre-Set Benefit Amounts: This policy offers fixed payments for specific medical events, regardless of the actual cost of the service. For example, if the plan states a $1,000 benefit for a hospital admission, it will pay this amount to the policyholder even if the hospital bill is higher or lower.
• Service Based Payouts: Benefit amounts vary depending on the type of care, such as daily rates for hospital stays, set amounts for surgeries, or flat fees for outpatient services. These structured payments help cover some or all out-of-pocket costs, but if the medical expenses exceed the benefit amount, the policyholder is responsible for the difference.
• Caps and Limits: This plan often includes caps on certain services, meaning it might limit the amount you can claim for particular treatments over a specified time frame (e.g., per day, per occurrence, or annually). These caps make it essential for policyholders to understand exactly what’s covered and prepare for potential costs beyond the fixed benefit.

United Healthcare Health ProtectorGuard (HPG):

• Fixed Payout Structure: HPG also operates on a fixed benefit model, paying a set cash amount per medical service as defined in the policy. For instance, it might offer $200 per doctor visit or $2,000 per hospital stay, regardless of the actual charge, which could be higher or lower.
• Defined Benefits by Service: Like Philadelphia American’s policy, HPG clearly specifies benefit amounts per service, allowing policyholders to know in advance what they’ll receive for each type of medical encounter. This can help in managing costs, but actual medical bills may vary significantly from the fixed benefits provided.
• Coverage Limitations: HPG includes specific limits on payouts per type of service (e.g., per day for hospital stays), as well as overall maximums. Policyholders should carefully review these limits to understand how the coverage aligns with their anticipated medical needs, especially since HPG is not intended to fully cover all medical expenses.

Key Comparison Points to Take Away:

Both plans offer structured, predictable payouts for medical services, which provides transparency for budgeting purposes. However, since they pay a fixed amount per incident rather than covering a percentage of the actual cost, policyholders may face out-of-pocket expenses if the fixed benefit falls short.

Key Differences in Coverage Caps and Benefits: 

Philadelphia American may have a broader or more varied range of benefits per service type, but both policies limit coverage through set benefit amounts and capped payouts. These policies are typically best used alongside primary health insurance to fill gaps rather than serve as comprehensive coverage solutions.

The Philadelphia American Indemnity Benefit Policy (Form H-0434) and United Healthcare’s Health ProtectorGuard (HPG) both operate on fixed-benefit structures but vary in the specifics of their coverage. Here’s a closer comparison of the key areas where they differ:

1. Hospitalization Coverage

• Philadelphia American: Pays a daily benefit for inpatient hospital stays, with amounts that depend on the plan level. Some versions also cover intensive care or surgery at higher rates, reflecting the intensity of care.
• United Healthcare (HPG): Offers a fixed benefit per hospital stay or per day in the hospital, often with an annual cap on covered days. Intensive care or surgery-related increases are generally not provided, which may limit coverage flexibility compared to Philadelphia American.

2. Doctor Visits and Outpatient Services

• Philadelphia American: Provides fixed payouts for outpatient services, including doctor visits, specialist consultations, and diagnostic tests (e.g., X-rays). Benefits are modest and capped by visit or service type annually.
• HPG: Pays a set amount per doctor visit or outpatient service, with annual limits on these visits. HPG’s payouts are generally lower, suitable for policyholders who need occasional outpatient coverage but not frequent visits.

3. Emergency and Urgent Care Coverage

• Philadelphia American: Covers emergency room visits and urgent care with a fixed amount per visit, but may cap the number of visits annually.
• HPG: Provides fixed payments for emergency or urgent care visits, often with stricter annual visit caps. HPG's emergency benefits may also be lower than comprehensive health insurance and any excess costs are the policyholder’s responsibility.

4. Surgical Benefits

• Philadelphia American: Covers surgeries with fixed benefits that vary based on procedure complexity, and some plans include anesthesia coverage. The benefit amounts increase for more complex surgeries.
• HPG: Pays fixed, often lower, amounts for surgeries with limited flexibility for complex procedures. Surgical benefits tend to be more standardized and less comprehensive compared to Philadelphia American.

5. Preventive Care and Wellness Benefits

• Philadelphia American: Some plans offer limited benefits for preventive care like annual wellness checks, though payouts are generally lower than for hospital or surgical coverage.
• HPG: Minimal preventive care benefits, focusing more on illness and injury-related services than routine wellness. Preventive care coverage is usually not comprehensive in either plan.

6. Prescription Drug Coverage

• Philadelphia American: Offers limited prescription benefits, typically capped annually or restricted to specific conditions. It’s intended as a supplement, not as full prescription coverage.
• HPG: May include limited prescription benefits, also capped either per prescription or annually. This coverage is suitable for occasional needs rather than ongoing prescriptions.

7. Specialty and Ancillary Services

• Philadelphia American: Some plans cover ancillary services like physical therapy or chiropractic care, with a per-visit cap and annual maximum.
• HPG: Also provides limited coverage for specialty services, with basic payouts and annual caps. Specialty services in both plans are limited in scope and benefit amounts.

Summary of Key Differences

• Philadelphia American offers more customizable and generally higher benefits for hospitalization, intensive care, and surgical procedures. It allows more flexibility with coverage tiers, making it potentially a stronger supplemental option for those needing varied benefit levels.
• United Healthcare HPG has a standardized, predictable fixed-benefit structure, which can simplify coverage but may offer lower benefits in some areas. HPG is designed for limited, consistent cash payouts rather than extensive, tailored coverage.

Both policies work well as supplementary options, but understanding the exact differences in benefits and caps can help policyholders choose the best fit for their healthcare needs.

Overall, Philadelphia American’s indemnity plan may be more comprehensive for those seeking higher payouts for inpatient and surgical care, while United Healthcare’s HPG offers straightforward, predictable payments suited for basic, fixed-amount coverage.

For managed care reimbursements, Philadelphia American's Indemnity Benefit Policy is generally the better choice compared to United Healthcare’s Health ProtectorGuard (HPG). Here’s why:

1. Alignment with Managed Care Reimbursement Models: Managed care reimbursement typically involves higher coverage for hospital stays, inpatient treatments, and surgical care, which are areas where Philadelphia American’s Indemnity Benefit Policy often provides more substantial benefits. Its structure allows for customized benefit tiers, which can better accommodate the varied costs of care associated with managed care plans.
2. More Comprehensive Payouts for Hospital and Surgical Services: Philadelphia American’s policy often includes tiered benefits that can better match managed care’s reimbursement rates for different types of services, including hospitalization, surgery, and outpatient procedures. These benefits can be adjusted based on the complexity and intensity of the service, which aligns well with managed care’s focus on reimbursing more extensive care.
3. Greater Flexibility in Service-Based Payouts: Managed care often involves a broad range of services, and Philadelphia American’s policy typically covers a wider array of treatments and specialties at higher benefit amounts. This flexibility can make Philadelphia American’s policy more compatible with covering the diverse needs and out-of-pocket costs associated with managed care.
4. Higher Benefits for Intensive Care and Emergency Services: Managed care often focuses on controlling costs while providing access to essential services like intensive care, which can be costly. Philadelphia American’s higher payouts for such services make it a stronger option, as it can help cover the gap left by managed care reimbursements more effectively than HPG.
5. More Robust Supplemental Coverage for Gaps: Managed care plans can leave gaps in coverage for certain procedures or high-cost services, and Philadelphia American’s Indemnity Benefit Policy is designed to offer more comprehensive supplemental payments. This can provide better financial protection by helping offset what managed care does not cover, whereas HPG’s standardized benefits may fall short in these areas.

In summary, Philadelphia American’s Indemnity Benefit Policy is generally better suited for managed care reimbursements, as it offers a more adaptable and comprehensive benefit structure that aligns well with the range of services and reimbursement levels typical in managed care models.

Philadelphia American’s Indemnity Benefit Policy (Form H-0434) may indeed offer more adaptability for managed care reimbursements compared to United Healthcare’s Health ProtectorGuard (HPG), largely due to its structured indemnity model and flexibility in applying benefits. Here’s a detailed breakdown of why Philadelphia American’s policy could be a better fit for those with managed care plans:

Advantages of Philadelphia American’s Indemnity Benefit Policy for Managed Care Reimbursements

1. Flexible Use of Benefits: Philadelphia American pays the policyholder directly, allowing the fixed benefits to be applied as needed, whether for co-pays, deductibles, or services not fully covered by managed care. This can be especially useful when out-of-pocket costs vary and offers the policyholder freedom to prioritize spending based on immediate needs.
2. Higher Payouts for High-Cost Services: The policy often provides higher benefit amounts for services like hospitalizations and surgeries, which can align with the larger expenses encountered within managed care. For example, managed care plans might cover only a portion of an inpatient stay, leaving the policyholder responsible for the rest. Philadelphia American’s higher fixed payouts help offset these costs and reduce the potential financial strain.
3. Supplementary to Managed Care: Philadelphia American’s indemnity design complements managed care plans well. Managed care focuses on cost management and often includes network limitations, which can leave policyholders with substantial costs if they need out-of-network or specialty care. The indemnity policy can help fill in these gaps, acting as a financial cushion when the managed care reimbursement is insufficient or restrictive.
4. Structured Payments for Hospital and Emergency Services: With its set benefits for inpatient, outpatient, and emergency services, Philadelphia American’s policy can cover remaining balances that managed care doesn’t fully address. For instance, if a managed care plan covers only a portion of emergency room charges, the indemnity benefit can cover the difference, making it a valuable supplement in high-cost scenarios.

Limitations of United Healthcare’s Health ProtectorGuard for Managed Care Reimbursements

• Lower Fixed Benefits: HPG generally offers lower payouts per service, which may not be enough to cover the remaining balance after managed care reimbursement. This limited payout could mean policyholders still face substantial out-of-pocket costs, especially for higher-cost treatments that managed care may only partially cover.
• Less Adaptability for Complex Claims: HPG’s fixed-amount, standardized approach may lack the flexibility needed to handle the variable expenses typical in managed care. If the actual service costs exceed HPG’s set benefits, the policyholder is left with a potentially larger financial gap.

Summary

In a managed care setting, where cost-sharing mechanisms like co-pays and deductibles are common, Philadelphia American’s Indemnity Benefit Policy stands out due to its higher payouts and flexibility in using benefits across different services. This adaptability makes it a more effective complement to managed care plans, especially for policyholders seeking financial relief for high-cost treatments or services that managed care may only partially cover.

United Healthcare’s Health ProtectorGuard (HPG) may indeed be the better choice in cases where policyholders value simplicity, affordability, and predictability, and have lower or specific healthcare needs. Here’s a summary of scenarios and types of policyholders who might benefit most from HPG’s structure:

1. Policyholders Seeking Simple, Predictable Coverage

• Why HPG Is Better: HPG’s fixed-amount payouts make it easy for policyholders to know exactly what to expect per service, minimizing complexity. This structure is ideal for those who don’t want to navigate variable benefits or tiered structures.
• Who Benefits: Younger individuals, healthy adults, or those with minimal healthcare needs who are mainly looking for straightforward coverage for occasional doctor visits, minor injuries, or routine services.

2. Individuals Needing Limited, Supplemental Coverage for Routine and Minor Medical Needs

• Why HPG Is Better: HPG’s benefit amounts are well-suited to cover smaller, predictable expenses, like routine doctor visits or minor ER visits. It’s optimal as a supplement for out-of-pocket costs rather than extensive medical coverage.
• Who Benefits: People with high-deductible health plans (HDHPs) who need coverage for minor, routine costs, such as co-pays or minor expenses, find value in HPG’s affordability. It’s also suitable for self-employed individuals or those without major health insurance who primarily want protection for basic, occasional expenses.

3. Individuals Comfortable with Network Restrictions

• Why HPG Is Better: HPG policyholders can benefit from UHC’s established network, accessing in-network providers with potential savings on negotiated rates. This can provide convenience and potential cost savings for those who prefer or are comfortable with network-based care.
• Who Benefits: Policyholders in urban or suburban areas with strong UHC network coverage, or those familiar with UHC’s system, benefit from easy access to in-network providers and lower costs by staying within the network.

4. Policyholders Seeking Budget-Friendly Premiums Over Comprehensive Coverage

• Why HPG Is Better: HPG’s lower premiums make it appealing for those prioritizing affordability and protection against minor, unexpected costs over comprehensive coverage. This appeals to people looking to keep insurance costs manageable.
• Who Benefits: Younger adults, part-time workers, or students seeking financial peace of mind at a low cost find HPG’s budget-friendly premiums attractive. This policy is also a good fit for those who don’t expect to need extensive healthcare services.

5. Those Wanting Supplemental Income Protection Rather than Full Medical Coverage

• Why HPG Is Better: HPG provides predictable payments that can supplement income for minor illnesses or injuries, making it a basic income protection option rather than full medical coverage.
• Who Benefits: People with primary insurance who want extra financial support for minor illnesses or injuries (e.g., to cover lost workdays) may find HPG helpful. It’s especially useful for those willing to handle some out-of-pocket medical expenses in exchange for fixed cash payouts.

Summary

United Healthcare’s Health ProtectorGuard (HPG) is well-suited for those who want simple, budget-friendly, and predictable coverage rather than comprehensive healthcare solutions. Its lower premiums and fixed benefits make it ideal for younger, healthier individuals or those seeking basic protection for occasional minor costs, particularly if they’re comfortable using UHC’s network. HPG offers an affordable option for those prioritizing cost control and simplicity in their coverage.