An Albany DPC Practice Charges $250 a Month. That's Above the $150 Line Federal Law Set for HSA Contributions.

Heirloom Family Medicine in Albany charges $250 per member per month. That’s well past what the American Academy of Family Physicians says most direct primary care costs, generally $50 to $100 a month. It also puts every paid tier at the practice, except a $1 tier for patients 100 and older, above a federal line that took effect this year.

The practice, run by Dr. Meghan Monthie, was the subject of a CBS 6 Albany report on Oct. 19 about what it called “a wave of physicians going out on their own, offering direct primary care.” One of Monthie’s patients keeps insurance through work alongside the membership, an approach Monthie told the station is common. “Health insurance is still very important for catastrophic events,” she said. “Some patients are opting for a higher deductible plan with lower healthcare premiums and pairing that with the direct primary care,” she said.

That pairing is exactly what IRS Notice 2026-5 was written about.

What $250 buys at Heirloom

The membership page lists four options:

• Foundation, $250 per member per month, with a one-time $150 enrollment fee per member, capped at $300 per family.
• Generations, a $600 monthly maximum for a family of up to two adults and their dependent children.
• Legacy, 10% off for paying a full year up front.
• Centenarian, $1 per member per month for patients 100 and older.

No long-term contract is required, and 30 days’ notice cancels.

The price pays for a small practice. The FAQ page says Heirloom keeps about 250 patients. AAFP puts the average DPC panel at 413. Visits run 30 to 90 minutes, and members reach Monthie by phone, text, secure message or email. She also makes home visits for newborns and postpartum patients. New patients join through a waitlist.

The practice calls this “concierge level of care without the concierge price tag.” Members can still use insurance for labs, imaging, prescriptions, specialists and hospital care, according to the FAQ.

One patient, Dominique Spagnola, told CBS 6 that Monthie got her to the specialists and testing that confirmed primary aldosteronism, a problem she had been looking into since 2022. “The monthly membership is something I don’t even notice,” Spagnola said.

Where the federal line sits

The One Big Beautiful Bill Act let direct primary care sit alongside a health savings account starting in 2026, and Notice 2026-5 is the IRS’s guidance on the terms Congress wrote. A membership leaves a patient eligible to contribute to an HSA only if the fees for that person stay at or under $150 a month, or $300 for an arrangement covering more than one person.

Heirloom’s numbers, set against that limit:

• One adult at $250 a month is $100 over the single limit.
• Two adults on Foundation are over the limit whichever figure applies. The notice doesn’t say whether two members are tested one by one against $150 or together against $300, but $250 each is above $150, and $500 together is above $300. The $600 family maximum is twice the $300 limit for an arrangement covering more than one person.
• Paying a year up front doesn’t close the gap. The notice’s own example puts a single person’s annual limit at $1,800 for 2026. By DPC Insider’s arithmetic, a $250 monthly fee with 10% off comes to $2,700 for the year.

Only the Centenarian tier comes in under the limit. Anyone in it who is enrolled in Medicare has a contribution limit of zero anyway, under IRS Publication 969.

What going over the limit does

Notice 2026-5 does not stop an HSA from paying a large membership fee.

Answer 20 of the notice says there is “no specific limit on the amount of the fixed periodic fee” for reimbursement purposes. Fees that exceed the monthly limit “will be treated as medical expenses reimbursable from an HSA,” the IRS wrote, “but will disqualify the covered individual from eligibility for making HSA contributions while the individual is enrolled.”

So the practice’s own FAQ is accurate when it says Heirloom “accepts HSA cards to pay for your membership.” It also tells members to check eligibility with a tax advisor and their HSA administrator. Those are two different questions. A member can spend money already in the account on the fee. That member can’t add new money to an HSA while enrolled.

For 2026 the notice lists the contribution limit at $4,400 for self-only coverage and $8,750 for family coverage. Those amounts are what a member in an HSA-eligible plan could otherwise put in.

All of this assumes Heirloom’s membership fits the rest of the federal definition: primary care only, from primary care practitioners, paid for by the fixed fee alone. DPC Insider isn’t deciding that question here.

The price that pays for the panel

Heirloom’s pricing and its panel come as a pair. With about 250 patients instead of 413, each membership has to carry a larger share of whatever the practice costs to run. That’s arithmetic, and it’s how a physician gets 90-minute visits and home visits after a birth.

The federal limit was drawn at $150 for one person. Publication 969 requires a high deductible health plan before anyone can contribute to an HSA. So the members Monthie describes, a higher-deductible plan plus the membership, are the ones for whom the limit can matter. Under Answer 20, a member like that can use the account to pay Heirloom and still give up the right to keep funding it.

How many of Heirloom’s members are in HSA-eligible plans would tell how many people this touches. For those who are, the partial answer the rules allow runs through the HSA balance a member already has. The model that makes a 250-patient panel work and the limit that keeps contributions open point in opposite directions, and for this practice, at these prices, there’s no tier that satisfies both.