Does Medicare cover concierge medicine?

What is concierge medicine?

Concierge care is when a doctor or group of doctors charges you a membership fee before they'll see you or accept you into their practice. After you pay the membership fee, you may get some services or amenities that Medicare doesn't cover. Concierge care is also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice or direct care.

Does Medicare pay the concierge membership fee?

No. You pay all costs for non-covered services, including the membership fee for concierge care, and Medicare.gov lists concierge care among the services Original Medicare doesn't cover. The fee depends on the contract or agreement you sign with the doctor or doctor group. Additional state laws and consumer protections may apply, and your state's insurance department or consumer protection bureau can tell you more.

What Medicare rules do concierge doctors have to follow?

Doctors who offer concierge care must still follow all Medicare rules, including these:

• Doctors who accept assignment can't charge you extra for Medicare-covered services, so the membership fee can't include extra charges for items or services Medicare usually covers, unless Medicare won't pay for the item or service.
• If the membership fee includes charges for an item or service Medicare usually covers but won't pay for, a doctor who accepts assignment must give you a written notice called an Advance Beneficiary Notice of Noncoverage (ABN) that lists the services and the reasons Medicare may not pay.
• Doctors who don't accept assignment can charge you more than the Medicare-approved amount for Medicare-covered services, but there's a 15% limit called the limiting charge.
• All Medicare doctors, whether or not they accept assignment, can charge you for items and services Medicare doesn't cover.

How does assignment change what I pay a concierge doctor?

A doctor who accepts assignment agrees to charge you only the Medicare deductible and coinsurance for covered services, has to submit your claim directly to Medicare, and can't charge you for submitting it. A doctor who doesn't accept assignment may ask you to pay the full amount at the time of service, should still submit a claim to Medicare for covered services, and in many cases can't charge more than 15% above the Medicare-approved amount. Most doctors accept assignment, but always check that yours does. See what Original Medicare costs.

What if a doctor has opted out of Medicare?

Medicare won't pay for items or services you get from a doctor who has opted out of Medicare, except in emergencies, even if the service is one Medicare covers. If you choose to see an opt-out doctor, you may need to pay upfront or set up a payment plan through a private contract with that doctor. Doctors opt out for at least 2 years at a time.