How Does Concierge Medicine Work with Insurance? Everything You Need to Know

You’ve decided you want a different kind of primary care. More time with your physician. Faster access when something comes up. A more proactive approach to your health.

But if you’re considering concierge medicine, you may be wondering how it fits with something you already have: health insurance.

Concierge medicine can work with health insurance. At many concierge practices, including PartnerMD, insurance is still billed for eligible medical services, while the concierge membership fee is paid separately for the additional access, time, and benefits included with membership.

That means joining a concierge practice generally doesn’t mean giving up your health insurance or paying out of pocket for every medical service you receive. But exactly how insurance works can vary by concierge practice, insurance plan, and whether you have private insurance or Medicare.

At PartnerMD, we’ve spent more than 20 years helping patients understand how concierge primary care works alongside private insurance and Medicare. Here’s what you need to know before deciding whether the model is right for you.

Key Takeaways

• Concierge medicine can work with health insurance. At PartnerMD, insurance is billed for eligible medical services, subject to the terms of your individual plan.
• You still need health insurance with concierge medicine. A concierge membership does not replace coverage for hospital care, specialists, emergency care, prescriptions, and other healthcare needs.
• Concierge medicine can work with Medicare. Medicare can continue to cover eligible medical services, while the membership fee is paid separately.
• Insurance participation varies. Not every concierge practice accepts insurance, and accepted plans can vary by practice and location.
• The concierge membership fee is separate from insurance. It covers membership benefits that are not billed to your health insurance.

How Does Concierge Medicine Work With Health Insurance?

Most concierge medicine practices work with health insurance much like a traditional primary care practice does. When you receive an eligible medical service, the practice bills your insurance, and any co-pays, deductibles, or coinsurance apply according to your individual plan.

The key difference is that you also pay a separate concierge membership fee. That fee is not billed to your health insurance and is separate from the medical services your insurance may cover.

An easy way to think about it is:

• Your health insurance: Pays its portion of eligible medical services, which may include office visits, laboratory testing, preventive screenings, and other covered care, depending on your plan.

• Your concierge membership: Gives you access to the additional benefits of the concierge model, such as greater access to your physician, longer appointments, same-day or next-day sick visits, 24/7 physician availability, care coordination, and health coaching. 

At PartnerMD, we accept most major insurance plans and Medicare. Because insurance participation can vary by location and individual plan, it’s important to confirm that your specific plan is accepted before joining.

Do I Still Need Health Insurance With Concierge Medicine?

Yes. Concierge medicine is not a replacement for health insurance. Your membership is designed to enhance your primary care experience, while health insurance provides financial coverage for a much broader range of medical care.

Even if your concierge physician handles much of your routine and preventive care, you may still need your health insurance for services such as:

• Hospital and emergency care
• Visits with specialists
• Surgeries and procedures
• Prescription medications
• Imaging and diagnostic testing performed outside your concierge practice
• Other medical care covered by your plan

Your insurance can also continue to cover eligible services you receive within a concierge practice that accepts your plan.

Think of concierge medicine and health insurance as serving two different but complementary purposes: your concierge membership changes how you access and experience primary care, while your health insurance helps cover eligible medical expenses across the broader healthcare system.

That’s why patients generally maintain health insurance even after joining a concierge practice.

Does Medicare Cover Concierge Medicine?

Medicare can work with concierge medicine. If your concierge physician participates in Medicare, Medicare can continue to cover eligible medical services according to its usual coverage rules.

At PartnerMD, we bill Medicare for eligible medical services, just as a traditional primary care practice would. Depending on the service and your coverage, Medicare may pay for eligible physician services, laboratory testing, preventive services, and other covered care.

Does Medicare Pay the Concierge Membership Fee?

No. Medicare does not pay for concierge membership fees. The membership fee is paid separately and covers the additional benefits included with your concierge membership.

What About Medicare Advantage?

Concierge medicine can also work with Medicare Advantage, but coverage and provider participation vary by plan. If you have Medicare Advantage, it’s important to confirm that your specific plan is accepted by the concierge practice before joining. 

Does Concierge Medicine Work With Medicaid?

Most concierge medicine practices, including PartnerMD, do not accept Medicaid.

Medicaid has specific rules governing covered services, participating providers, and what patients can be charged. Because of these requirements, the traditional concierge model, which includes a separate membership fee, may not be compatible with Medicaid coverage.

If you have Medicaid, it’s important to confirm a practice’s participation and payment policies before joining.

What If a Concierge Practice Doesn't Accept Insurance?

Some concierge practices do not accept or bill health insurance. Instead, they operate on a cash-pay basis.

You may also encounter a different membership-based model called direct primary care, or DPC. Like concierge medicine, DPC typically charges a monthly or annual membership fee.

However, DPC practices generally do not bill insurance for primary care services. Instead, the membership fee typically covers a defined set of primary care services provided by the practice.

This is different from the model used at PartnerMD, where insurance is billed for eligible medical services and the membership fee is paid separately for the additional benefits of membership.

Because the terms concierge medicine, membership medicine, and direct primary care are sometimes used interchangeably, it’s important to ask any practice you’re considering whether it accepts your insurance and exactly what its membership fee includes.

What Does a Concierge Membership Fee Pay For?

If health insurance still covers eligible medical services, you may wonder what the concierge membership fee is actually for.

The membership fee supports the additional access, time, and services that distinguish concierge medicine from traditional primary care and are not typically reimbursed by health insurance.

At PartnerMD, membership benefits include:

• Direct, 24/7 access to a physician
• Same-day or next-day sick visits
• More time with your physician, including 30-minute appointments
• Little to no time spent in the waiting room
• Coordination with specialists
• Easier communication with your care team between appointments
• A dedicated health coach to help you work toward your health and wellness goals
• A more proactive approach to prevention and long-term health

These benefits are possible in large part because concierge physicians care for significantly fewer patients than traditional primary care physicians, giving them more time to know their patients, understand their health history, and remain accessible when they need care.

The membership fee is therefore separate from both your health insurance premium and any co-pays, deductibles, or coinsurance you may owe for medical services.

Choosing the Right Combination of Concierge Care and Insurance

Concierge medicine and health insurance can work together, but exactly how they work together depends on the practice and your individual insurance plan.

Before joining a concierge practice, make sure you understand:

• Whether the practice accepts your specific insurance plan
• Which medical services will be billed to insurance
• What the concierge membership fee includes
• What co-pays, deductibles, or coinsurance you may still be responsible for
• How the practice works with Medicare or Medicare Advantage, if applicable

At PartnerMD, our membership team can explain how membership works, which insurance plans are accepted in your area, and what you can expect before you join.

Schedule a call with a membership expert to get answers to your questions and learn whether PartnerMD is right for you.