A Maryland Family Doctor Wants DPC Paired With Marketplace Insurance. Federal Tax Law Already Allows Part of It.

Dr. Dimitri Coupet opened an independent family medicine practice in Laurel, Maryland, expecting to give patients time. He found a payment system that rewards the opposite. “The financial prescription is always the same,” he wrote in an op-ed for Maryland Matters on Oct. 11. “See more patients, shorten visits and move faster.”

His answer is a state experiment. Maryland, he argues, should test “a marketplace insurance designed to work with direct primary care.” Patients would pay a DPC physician a monthly membership. A marketplace plan would cover hospitalization, specialists, emergency care, prescriptions and imaging. Subsidies would go toward the insurance.

He even put numbers on it. “Imagine an eligible Marylander paying about $100 monthly for DPC and no more than $100 for subsidized insurance,” he wrote. The state would then measure whether that pairing cuts emergency visits, hospitalizations and total insurance spending.

The proposal reads like a new idea. A lot of it is already on the books.

What a Marylander can do today

Since January, federal tax law has done some of what Coupet describes. IRS Notice 2026-5, which implements the HSA changes in last year’s reconciliation law, says that for months after Dec. 31, 2025, “a bronze or catastrophic plan will be treated as an HDHP if the plan is available as individual coverage through an Exchange.”

That matters because the same law created a federal definition of a direct primary care service arrangement. A membership that meets that definition no longer blocks HSA contributions. Under the notice, the arrangement has to cover primary care only, be paid only through the fixed fee, and include no prescription drugs other than vaccines. The fees also have to stay at or under $150 a month for one person, or $300 for an arrangement covering more than one. A membership that bundles prescription drugs, or bills separately for its primary care, falls outside that definition, even at $100 a month. That limit is adjusted for inflation after 2026.

Put those two rules together and you get something close to Coupet’s pairing. A Marylander might buy a bronze plan through Maryland Health Connection, open an HSA, and pay a $100 DPC membership out of it. The $100 figure in the op-ed sits inside the $150 ceiling, and inside the $50 to $100 range the AAFP gives for typical DPC fees.

Federal marketplace rules leave a door open, too. Under 45 CFR 156.245, “a QHP issuer may provide coverage through a direct primary care medical home that meets criteria established by HHS,” provided the DPC services are coordinated with the insurer. So a marketplace plan built around DPC is something federal rules already contemplate.

What still needs the state

Two pieces of Coupet’s plan would need the state.

The first is a plan priced around DPC. The HSA route above stacks two separate products, and nothing in Notice 2026-5 prices the insurance around the membership. Coupet wants insurance “designed to work with” the membership, which would mean an issuer and the state deciding that a DPC member’s coverage can cost less.

The second is measurement. Coupet’s case rests on Maryland’s crowded emergency departments. He wrote that “a substantial share of emergency-department use involves problems that are non-emergent, primary-care treatable or potentially avoidable with timely outpatient care.” A pilot would test whether DPC members actually show up there less often. Stacking a bronze plan and a membership on your own produces no such data.

He named two routes: a Section 1332 waiver, or a pilot run through the Maryland Health Benefit Exchange. Maryland is no stranger to the first. The state already holds a 1332 waiver for its reinsurance program, which federal regulators extended for plan years 2024 through 2028. Any 1332 waiver has to clear four federal tests. Coverage under the waiver must be at least as broad and as affordable as it would be without it, it must reach a comparable number of people, and it must not add to the federal deficit.

A 1332 waiver for a DPC pilot would have to show it passes all four.

The AHEAD problem he’s describing

Coupet’s sharpest line is aimed at Maryland’s own primary care strategy. The state moved to the federal AHEAD Model on Jan. 1, 2026, and the Maryland Primary Care Program continues under it.

He gives AHEAD credit for linking primary care and hospital use. He also says it shows “our tendency to respond to complexity with more complexity: quality measures, reporting requirements and multiple program pathways.” Large health systems, he wrote, can hire teams to manage those obligations. Small independent practices often cannot.

His op-ed doesn’t say his own practice runs on memberships. He writes as an independent physician who now understands “why doctors sell to larger systems, reduce clinical work or leave primary care entirely.” That makes the proposal more interesting, because he argues for DPC without claiming to run a DPC practice himself.

The Counterargument

The strongest objection to this post’s framing is that “already allowed” isn’t the same as “already working.” The HSA route helps people who can afford to put money into an HSA. The bronze plan still carries high cost-sharing. And nothing in the federal rules asks whether a Marylander who stacks these products uses the ER less often.

That objection lands. The federal changes made the pairing HSA-compatible. They don’t measure whether it works.

But it also narrows what Maryland would actually have to build. The state doesn’t need to invent a legal structure for DPC alongside marketplace coverage. It needs a priced product and a data plan. If you practice in Maryland and have been watching AHEAD’s reporting load grow, that is a much smaller ask than the op-ed’s headline suggests, and a more realistic one to bring to the Exchange.