There are three structural paths and the right one depends on your scale, infrastructure, and how much operational overhead you can absorb. The OBBBA changes that took effect January 2026 made one of those paths — ICHRA-funded individual relationships — substantially easier than it used to be.

The Three Paths

1. Direct contracting with self-funded employers. A per-employee-per-month (PEPM) flat-fee carve-out: the employer pays you a defined monthly fee per enrolled employee (plus tiered amounts for spouse/dependents), and you sit alongside the employer's third-party administrator (TPA), stop-loss carrier, and pharmacy benefit manager. Your DPC handles primary care outside the claims stream; the TPA continues to adjudicate specialist, hospital, and ancillary claims. Highest commitment, highest revenue per relationship, most operational lift.

2. ICHRA or QSEHRA route. No formal employer contract required. The employer funds an Individual Coverage HRA (ICHRA) or — for under 50 FTEs — a Qualified Small Employer HRA (QSEHRA). The employee uses the allowance to buy individual coverage (often a bronze or catastrophic ACA plan, which OBBBA now classifies as HDHPs), then pays your DPC membership separately from their HSA. You attract these patients as retail members; a soft "preferred provider" letter the employer hands out at onboarding is enough to drive enrollment without the eligibility-file overhead of a PEPM contract. This path is the 2026 unlock: pre-OBBBA, the HDHP-plus-HSA-plus-DPC stack didn't work cleanly. It does now.

3. Aggregator networks. Hint Connect and DPC-X (Direct Primary Care Xchange) bundle independent DPC clinics into a single contractable network. If you want enterprise / geo-distributed employer deals without building a multi-state footprint yourself, this is the lever. You give up some margin and some account control; you gain access to deals you couldn't land solo.

Readiness Checklist

Before pitching employers, regardless of path, you need:

• EMR with structured reporting hooks. You will be asked for quarterly utilization data: ER visits avoided, urgent care avoided, specialist referral rate, chronic-disease control metrics (HbA1c, BP, lipids), engagement rate, and dollar-savings vs. baseline cohort. If you can't pull this without manual chart review, you can't keep an employer contract for a second year.
• Defined panel capacity. Solo DPC norms run 400–600 at maturity for typical retail practices; well-staffed practices ready to support employer contracts often push to 600–800 with a hard ceiling around 1,000. Employers will ask; have a real number.
• Insurance stack. Malpractice (non-negotiable even in states that don't require it), general/commercial liability, and increasingly cyber liability for 100+ life groups. DPC Frontier's malpractice page is the standard reference.
• Entity structure. PC or PLLC for physician-owned practices in most states; check your state's professional-entity rules before forming. None of these structures shield personal malpractice liability — that's what insurance is for.
• Staffing for eligibility operations. Larger employers push ~50 membership changes per month (hires, terminations, dependent updates). At least a part-time admin person to reconcile eligibility files against your membership management system is table stakes.
• Multi-clinic story. If you're pitching geo-distributed employers, either you have multiple locations or you're part of a network. Solo single-location practices should focus on local self-funded employers and the ICHRA/QSEHRA channel.

How Deals Actually Get Sourced

Cold-pitching benefits managers without a broker introduction is the slow road. Deals close through aligned channels:

• Health Rosetta DPC-X — national marketplace explicitly built to link DPC practices with Rosetta-certified benefits advisors. The brokers in this network are pre-trained on value-based design with DPC at the foundation.
• Hint Connect — Hint Health's aggregator network. One contract spans many independent clinics nationwide, which is what large multi-state employers need.
• NABIP local chapters — most National Association of Benefits and Insurance Professionals brokers still default to carrier plans, but state and local chapters increasingly host DPC education sessions. Warmest cold-outreach surface you'll find.
• Level-funded carriers and captives. Allied National and similar level-funded administrators actively pair their plans with DPC as the primary-care layer. Group captives — Roundstone is the most DPC-friendly — pair DPC with stop-loss captive design.
• Conferences. Hint Summit, DPC Summit (AAFP-sponsored), Health Rosetta Summit, DPCA Access. NABIP Capitol Conference for federal-policy exposure.
• DPC Frontier — Dr. Phil Eskew's repository of contract templates, distributed by request. A meaningful head start on initial drafting; still get a healthcare attorney to review for state-specific issues.

Pricing Benchmarks

National PEPM range is $50–$125 per employee per month for comprehensive primary care, with regional and acuity variation. Urban coastal markets push toward the upper end; rural Midwest sits at the lower end. Tiered structures typically look like: employee only $75–$95, employee + spouse $130–$170, family $180–$250, with child-only add-ons of $20–$30 per dependent.

Most practices discount employer PEPM 10–25% below retail in exchange for volume and predictable billing. Setup fees of $1,000–$5,000 and per-employee onboarding fees of $25–$50 are common; both are usually waived above a certain volume.

The $150/$300 Cap — Price Carefully

The OBBBA cap is the single most important number to understand when pricing employer deals. It is not a ceiling on what your employer client can pay — it's a definitional threshold for whether the arrangement qualifies as a "Direct Primary Care Service Arrangement" under IRC §223(c)(1)(E).

If your aggregate monthly fee — regardless of who's writing the check — exceeds $150 individual / $300 family, the arrangement falls outside the safe harbor entirely. Two consequences:

1. The DPC fee is no longer an HSA-qualified §213(d) expense.
2. The arrangement may be treated as disqualifying "other coverage" that closes the employee's HSA eligibility entirely — the same problem the old IRS Notice 2018-12 created pre-OBBBA.

You can still charge PEPM above the cap, but it needs structural care. The common play is to set the DPCSA-qualifying portion at exactly $150 (or $300) and structure any excess as a separate benefit (a la carte service fees, wellness wrap, telehealth supplement) that doesn't count toward the safe-harbor cap. Run the structure past a healthcare attorney before you sign.

What OBBBA Changed for Employer Plans

Two things that simplify the math compared to pre-2026:

• Employer-paid DPC contributions qualifying as DPCSAs are excluded from employee gross income per IRS Notice 2026-05. Treasury guidance also indicates the qualifying portion isn't subject to federal payroll taxes (FICA/FUTA). Pre-OBBBA, conservative payroll vendors often imputed income for direct employer payments; that ambiguity is resolved for arrangements that stay inside the safe harbor.
• HDHP-plus-HSA-plus-DPC is now a clean stack for ICHRA-funded employees, because bronze and catastrophic ACA plans are statutorily HDHPs as of January 1, 2026.

One open question: whether an HRA can reimburse DPC fees directly (versus only reimbursing premiums) without breaking the employee's HSA eligibility. Notice 2026-05 flagged this for public comment; comments close March 6, 2026. Until Treasury resolves it, the safer plan-document structure is "HRA reimburses premium, HSA pays the DPC fee."

Common Pitfalls That Kill Deals

• Hostile TPAs. Among the biggest deal killers in the field. Carrier-aligned TPAs see DPC as competitive shrinkage of their book and will slow-walk or sabotage integration. Bring a DPC-friendly TPA into the deal if the employer's existing TPA is the problem.
• Stop-loss carve-out gaps. Stop-loss carriers can deny reimbursement if the TPA and the carrier aren't aligned on DPC-routed care. Have the broker confirm carve-out language before the contract is signed.
• State regulatory traps. A handful of states (historically Missouri, occasionally others) require the DPC agreement to be patient-to-physician — direct employer-to-physician payment can be reclassified as insurance. Solution: route payment through an HRA or have the employee sign the patient agreement individually with employer-funded payment.
• ERISA exposure. Structured wrong, an employer-paid DPC arrangement can look like an ERISA welfare benefit plan with all the compliance overhead. DPC Frontier's ERISA page is the canonical reference.
• Concentration risk. Practices regret deals when a single employer becomes more than 30% of revenue and then renegotiates or exits.
• Unilateral amendment clauses. Contracts that let the aggregator or employer amend terms without your consent. The Association of American Physicians and Surgeons flags this as a routine red flag.

Real-World Proof Points

Three documented cases worth citing to skeptical employers:

• Rosen Hotels & Resorts (Orlando). Long-running on-site/near-site DPC clinic with documented cumulative savings vs. industry-peer hospitality companies; per-capita spend ~50% below the industry average. Health Rosetta case study.
• DigitalGlobe + Nextera Healthcare. Multi-month case study showing significant claims-cost reduction; led to company-wide DPC rollout. Case study.
• Union County Public Schools. Large-N claims analysis showing meaningfully lower urgent-care and inpatient utilization compared to baseline. PR Newswire summary.

See Also

• How do I start a DPC practice?
• I'm burned out on corporate medicine — is DPC a realistic alternative?
• Can you contribute to an HSA if your employer offers an HRA? — the seeker-side companion to the ICHRA/HSA stacking discussion above.

Before You Sign

This FAQ is general information, not tax or legal advice. Employer-sponsored DPC contracts touch tax (HSA, HRA, FICA), employment law (ERISA), and state insurance regulation — get a CPA on the tax structure and a healthcare attorney on the contract terms before you sign your first employer deal. The reward of getting it right is sustainable employer revenue; the cost of getting it wrong is your employer client's employees losing their HSAs.

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