Many people considering concierge medicine are on Medicare, and the first thing they want to know is whether Medicare will pay for it. The answer has two parts. Medicare does not pay the concierge fee. It does continue to cover the medical care you receive, the same way it would at any doctor’s office. Here is how that works.

What Medicare says

Medicare’s own page on concierge care is direct: Medicare does not cover concierge fees. You pay the fee yourself. Medicare also notes that concierge care goes by other names, including retainer-based medicine, boutique medicine and direct care, so the same rule applies whatever a practice calls itself.

Medicare adds that the fee depends on the agreement you sign with the doctor or group, and that state laws and consumer protections may also apply.

Doctors still follow Medicare rules

A concierge doctor who works with Medicare has to follow all Medicare rules. The most important one for patients involves assignment. A doctor who accepts assignment agrees to take the Medicare-approved amount as full payment for a covered service, and can bill you only for the deductible and coinsurance.

According to Medicare, a doctor who accepts assignment cannot charge you extra for Medicare-covered services, and the concierge fee cannot include extra charges for things Medicare usually covers. If Medicare will not pay for a particular item or service, the doctor must give you a written notice, called an Advance Beneficiary Notice of Noncoverage, before charging you for it.

Doctors who do not accept assignment can charge more than the Medicare-approved amount for covered services, up to a 15 percent limit called the limiting charge. Any Medicare doctor can charge for services Medicare does not cover at all. It is reasonable to ask a practice directly whether it accepts assignment.

What is billed to Medicare at a concierge practice

At a concierge practice that works with Medicare, the medical care itself is billed the usual way. Medicare Part B covers medically necessary doctor services and preventive care, so a typical year might include:

  • Office visits when you are sick or need follow-up.
  • Lab work and other tests that are medically necessary.
  • Your yearly wellness visit, which Medicare covers for people who have had Part B for more than 12 months.
  • Covered preventive screenings, based on your age and history.

Your Part B deductible and coinsurance, or any supplemental coverage you have, work the same way they would anywhere else. The concierge fee sits outside that system.

What the concierge fee is for

If Medicare covers the care, people reasonably ask what the fee buys. In most concierge practices it pays for the way care is delivered: a smaller panel, faster appointments, more time at each visit and easier access to the doctor. Medicare describes this as getting services or amenities that Medicare does not cover.

Each practice defines this differently, so ask for the agreement in writing and read what the fee includes. Our article on how much concierge medicine costs has questions that help.

Questions to ask about Medicare

A few direct questions will tell you most of what you need to know before joining a concierge practice as a Medicare patient:

  1. Do you accept Medicare assignment?
  2. Which services do you bill to Medicare, and which are covered by the membership?
  3. Will I ever be asked to sign an Advance Beneficiary Notice, and for what?
  4. Do you work with my supplemental or Medicare Advantage plan?

A note on Medicare Advantage

If you have a Medicare Advantage plan rather than Original Medicare, the plan’s network rules also matter. Before you join any practice, check with your plan that the doctor is in network, so that your visits and tests are covered the way you expect. The concierge fee is still not covered.

How Legacy Medical works with Medicare

Legacy Medical bills Medicare for visits, labs and tests, along with other insurance such as Aetna, Cigna and BlueCross BlueShield. The annual concierge fee is separate and is not billed to insurance. Labs are drawn in our office, and members have a yearly executive physical with labs and an ECG. Our insurance and fees page and our frequently asked questions cover the common billing questions.

Many of our patients are retirees and seasonal residents who want a doctor they can reach easily. If you would like to see how the practice would fit with your Medicare coverage, start with a complimentary meet and greet with Dr. Shtern. Family members are welcome.

This article is general information, not advice for your situation. Members can call the office with questions about their own care.