Concierge Medicine and Medicare: The Rules That Apply

What Medicare says

Medicare's own consumer page on concierge care makes four points that anyone with Medicare should know.

1. Medicare does not cover membership fees. You pay the fee yourself, along with any other non-covered services.
2. Doctors must still follow all Medicare rules. Charging a fee does not exempt a practice.
3. Doctors who accept assignment cannot charge you extra for Medicare-covered services.
4. The membership fee cannot include additional charges for items or services that Medicare usually covers, unless Medicare will not pay for the item or service. In that situation, the doctor must give you a written notice called an Advance Beneficiary Notice of Noncoverage.

Medicare also notes that state laws and consumer protections may apply.

Why the fee has limits

Medicare sets what a participating physician can collect for a covered service: the Medicare payment plus your deductible and coinsurance. Asking for more is a problem.

The Office of Inspector General at the U.S. Department of Health and Human Services addressed this in a 2004 alert. It described a physician who asked patients to sign a $600 annual contract covering things such as care coordination and a comprehensive health assessment. The OIG alleged that some of those services were already covered by Medicare, and the physician agreed to a settlement and stopped offering the contracts.

In its guidance for physicians, the OIG says that an access or administrative fee that simply allows patients to obtain Medicare-covered services from a practice constitutes double billing.

For you as a patient, the takeaway is practical: a membership fee in a Medicare-participating practice should be for services Medicare does not cover. It is reasonable to ask a practice what, specifically, the fee pays for.

The key question: what is the physician's Medicare status?

How Medicare works with a concierge practice depends on which of three categories the physician falls into. Medicare.gov explains them here.

If the physician has opted out

Opting out is a formal step. According to Medicare.gov and the Centers for Medicare & Medicaid Services:

• Providers opt out for a minimum of two years, and the status renews automatically.
• The physician must sign a private contract with each Medicare patient.
• Medicare will not pay for the services you get from that physician, even if Medicare would normally cover them.
• A private contract cannot be used for emergency or urgent care.
• The physician cannot opt out for some patients or some services only.

CMS policy also requires the private contract to state that Medigap plans do not pay for services Medicare does not pay for, and that other supplemental plans may choose not to.

Opting out applies to that physician. Your Medicare coverage remains in place for hospitals, specialists, and other providers who accept Medicare.

Good to know. You are never required to sign a private contract. You can choose a physician who accepts Medicare instead.

What a membership may include for Medicare patients

Because the fee cannot duplicate covered services, practices that participate in Medicare generally describe their memberships in terms of things Medicare does not pay for. Which services are "non-covered" is a technical question, and practices are responsible for getting it right. As a patient, you can ask:

• What exactly does the fee cover that Medicare does not?
• Will you bill Medicare for my office visits and my annual wellness visit?
• If you believe Medicare will not pay for something, will I receive an Advance Beneficiary Notice first?

Medicare Advantage and Medigap

If you are in a Medicare Advantage plan, your plan has its own network and rules. Ask the plan whether the physician is in network and how the plan treats the membership. If you have a Medigap policy, remember that it supplements Original Medicare's coverage, and Medicare does not cover the fee.

How common is this?

When the GAO studied concierge care for Congress using 2004 data, it found that the number of concierge physicians was small, which made it unlikely at that time that the approach had contributed to widespread access problems for Medicare beneficiaries. That finding is two decades old. Concierge practice has grown since, and we have not found a comparable recent federal study.

Before you join: a Medicare checklist

• Is the physician participating, non-participating, or opted out?
• If opted out, what will each visit cost me, and what would I sign?
• What does the membership fee cover that Medicare does not?
• Will the practice bill Medicare for covered services?
• What happens to prepaid fees if I cancel?

For help with your own situation, your State Health Insurance Assistance Program (SHIP) offers free, unbiased Medicare counseling, and 1-800-MEDICARE can answer coverage questions.