How Does Concierge Medicine Work with Insurance?
written by
Veronica Max, APRN, FNP-C
TLDR: Most concierge medical practices do not accept insurance. The high quality of care provided by a concierge practice is not possible within the model of insurance-based care. You can still use your insurance to pay for labs, imaging, specialist appointments and/or hospital visits.
Most concierge practices do not accept health insurance, but it shakes out to being better for most people that way. Employing your primary care physician directly without the health insurance middleman means you get the care you need on your terms.
Health insurance coverage is intentionally confusing, and it can be a challenge understanding what your insurance does and does not cover. Here’s what you need to know.
Does Health Insurance Cover Concierge Medicine?
In short, health insurance does not cover concierge membership fees.
If you have health insurance, you can still join a concierge practice but you must pay for any monthly fees or annual fees out of pocket. Trust me when I say concierge doctors are worth this extra expense. You get the benefit of the personalized care, same-day appointments, non-existent wait times, relaxed office visits and overall direct access to your health care provider because they are seeing fewer patients.
If you have a flexible spending account (FSA) or health savings account (HSA), your membership fees may be considered an eligible expense for these pre-tax dollars. However, not all HSA or FSA providers consider concierge membership an allowable expense. If you have one of these accounts check with the plan administrator to confirm whether or not they cooperate with concierge practices.
In addition, you can still use your health insurance for healthcare expenses incurred outside of your concierge physician’s office. This could include labs, imaging, medications, specialist appointments and ER/hospital visits – although these things are often cheaper via self-pay routes.
Keep in mind that if you have an HMO plan, you will still need a PCP contracted with your health insurance plan in the event you need a referral. HMO health insurance plans only pay for specialists if you have been referred by your HMO-contracted PCP.
Does Concierge Medicine Work with Medicare?
Like private health insurance companies, Medicare does not cover concierge membership fees.
This means you will be responsible for your membership fees out-of-pocket, but you can still use Medicare for your services like bloodwork, imaging, medications, and specialist appointments. Keep in mind that you are still out of pocket for any expenses incurred until your deductible is met.
It is important to note that some concierge medicine practices do not accept Medicare patients - regardless of whether or not you are willing to pay out of pocket for the membership dues. This is due to federal regulations that require extra paperwork and red tape in order to bill Medicare patients directly.
While Medicaid coverage varies by state, there are currently no Medicaid programs that cover concierge services.
What Insurance Does and Does Not Cover for Concierge Care
When it comes to concierge care and health insurance, the overarching principles of coverage are rather simple–insurance does not cover membership fees, but it will still cover you for medical services and procedures outside of your concierge practice.
This includes (but is not limited to):
Routine labs
Medications
Imaging
Specialist appointments
Emergency room visits and hospitalizations
Depending on the plan administrator, you may be able to use your FSA or HSA to pay for membership fees with pre-tax dollars.
Do I Still Need Insurance if I See a Concierge Doctor?
You need some sort of catastrophic healthcare coverage, but traditional health insurance isn’t your only option.
Your concierge membership covers “routine healthcare expenses”. This is what most people access healthcare for 99% of the time. It includes most things that happen within your concierge doctor’s office. For example, things like:
Wellness exams (ie. well woman exam with PAP, well child checks)
Illness and injury visits
Routine in-office procedures like IUD removal, suturing or rapid point-of-care testing (ie. strep or flu swabs)
Membership does NOT cover things that happen outside of your concierge practice. This includes things like:
ER visits
Hospital stays
Specialist consultations
For the rare medical events that result in the utilization of these services, we recommend that you carry some sort of catastrophic health coverage.
Traditional health insurance isn’t your only option.
In fact, traditional health insurance is probably not the best option for you if you are young and/or otherwise healthy.
Healthshares and peer-to-peer healthcare funding plans are often better, more cost-effective options for people who take radical personal responsibility for their health.
This is because these services can exclude people from membership based on pre-existing conditions. Some people say that’s unfair. I say it promotes personal responsibility and skin in the game. It also keeps premiums down.
Plus, they typically cover more pre-existing conditions than you’d think. For instance, people with “controlled”/well-managed chronic conditions are typically still eligible for having any events related to these conditions covered after a clearly specified waiting period.
Between a concierge membership + an alternative catastrophic plan, you can get better care and more comprehensive coverage for LESS than a traditional health insurance policy
But not all healthshares and peer-to-peer healthcare funding companies are created equal. Some are better than others. The two companies I recommend are:
Another nice perk about healthshares? They have no network (you can see anyone you want), and they typically cover you out of state and even out of the country!
Conclusion
Health insurance won’t cover your concierge membership fee, but it can still cover any catastrophic medical expenses you accrue outside of your concierge doctor’s office.
If you’re young and/or otherwise healthy, you might even consider switching to an alternative catastrophic coverage option and actually get better, more comprehensive coverage for less.
If you have any questions or are interested in learning more about how you can get access to concierge care designed for sovereign individuals, please visit UltraPersonal.healthcare or call us @ 512-489-9813.