Does Health Insurance Cover Concierge Medicine?

Does health insurance cover concierge medicine? Are there strategies for getting the most out of your health insurance with respect to concierge medicine?

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The answers are: sometimes, and yes.

How Concierge Medicine Works

Concierge medicine is a heath care model in which a patient pays a fee – monthly, biannually or annually – directly to their doctor for the practice’s services. Under this model, consumers have access to their doctor or another physician in the practice whenever they want. Patients can make same-day appointments with little or no waiting.

This framework is similar to an arrangement of a client who keeps an attorney on retainer. Such clients can obtain legal services whenever they need them and don’t pay by the hour or case.

Concierge Medicine Costs

As for costs, the annual fee to subscribe to most concierge medicine practices ranges between $1,200 and $3,000, according to conciergemedicinetoday.org. Some high-end concierge medicine practices that provide services to well-off patients can cost tens of thousands of dollars a year, experts say.

Most concierge medical practices don’t take health insurance.

Here is the breakdown of payment options that concierge medicine practices accept, according to conciergemedicinetoday.org:

  • Cash only, 51%
  • Medicare or some insurance, 29%
  • Medicare but no HMO or PPO plans, 14%
  • Insurance but no Medicare, 6%

What Health Insurance Does and Does Not Cover

Here are the ways you can use health insurance for concierge medicine:

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Medicare or some insurance. If you have Medicare or other health insurance, you can join a concierge medical practice, but you’ll have to pay the membership fee yourself. Regarding Medicare, a concierge medical practice “can’t include additional charges for items or services that Medicare usually covers unless Medicare won’t pay for the item or service,” according to Medicare.gov. In those situations, your physician must give you a written notice, known as an “Advance Beneficiary Notice of Noncoverage,” listing the services and reasons why Medicare may not pay. In such situations, a concierge practice may seek to impose additional fees for services not covered by Medicare, says Michael Seavers, the program lead in Healthcare Informatics at Harrisburg University of Science and Technology in Harrisburg, Pennsylvania. He notes that Medicare isn’t only used by older people. Individuals under age 65 with certain medical conditions, like renal failure, may also qualify for Medicare.

Similarly, if you have private health insurance, you must pay the fee yourself to become a patient in a concierge practice, says Dr. Amna Husain, a pediatrician and the founder of Pure Direct Pediatrics. That’s a concierge practice in Marlboro, New Jersey. “This fee will include the normal care you received from a non-concierge doctor with the added personal medical amenities the concierge practice offers,” she says.

You may be able to use Medicare or other health insurance to pay for items and services the concierge practice doesn’t provide, which can include:

  • Prescription medications.
  • Lab work.
  • Imaging.
  • Emergency department visits and hospitalizations.

Doctors who accept assignment can’t charge you extra for Medicare-covered services. (In the context of Medicare, “assignment” means your health care provider agrees to accept the amount approved by Medicare as full payment for services.) This means the membership fee can’t include additional charges for items or services that Medicare usually covers unless Medicare won’t pay for the item or service. In this situation, your doctor must give you a written notice called an “Advance Beneficiary Notice of Noncoverage” listing the services and reasons why Medicare may not pay.

Medicare but no HMO or PPO plans. HMO and PPO plans are more focused on primary care physicians and specialists. If you pay to be part of a concierge medical practice, you can use your HMO or PPO to see a specialist, Husain says. For example, if your concierge practice doesn’t have a cardiologist, you could use your HMO or PPO to see such a specialist. It’s important to keep in mind that HMOs limit the number of places a patient can go for health services. Therefore, concierge medicine may not be the best fit for someone with an HMO. Husain notes that concierge physicians often work in private practice, not under the auspices of academic hospitals or health care networks. “They might choose to send a patient to a sub-specialist that’s suited to the patient’s condition” but doesn’t participate in an HMO plan, Husain says.

Insurance, but no Medicare. Most of Husain’s patients fall under this category. “My practice strictly charges cash or the credit card on file for my membership amenities,” she says.

Patients can use their insurance for such health care products and services as:

  • Prescription medications.
  • Lab work.
  • Imaging.
  • Emergency room visits.
  • Hospitalizations.

Tips for Concierge Patients With Health Insurance

Before you sign up with a concierge medical practice, do these three things, Husain advises:

  • Consider the costs.
  • Review services not covered by the practice.
  • Interview the physician.

1. Consider the costs. Husain encourages patients to think about the costs of joining her practice and advises them to take their time to make the right decision for them. “While it does come with additional out-of-pocket expenses, there are many benefits, including personalized care and individual attention with longer appointments and less hassle,” she says. Take the time to evaluate what you want from your physician, the practice you choose and your insurance benefits.

2. Review services not covered by the practice. Health care consumers should carefully review what services the concierge medical practice that they’re considering doesn’t offer.

Services concierge practices may not offer include:

  • Vaccinations.
  • Blood work.
  • Home visits after hours.
  • Imaging.

3. Interview the physician. “This is an incredibly important relationship and one you want to feel confident in,” Husain says. “I encourage prospective parents to talk to potential pediatrician candidates about important topics, such as breastfeeding, bottle-feeding, vaccines, antibiotic prescribing practices and mental health.” You’ll want to know the doctor’s viewpoints on these and other topics.

Copyright 2020 U.S. News & World Report

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