Does Insurance Cover Concierge Medicine and What You Need to Know

Concierge medicine can be a game-changer for those who value personalized care. However, one major concern is whether insurance covers these high-end medical services.

Insurance companies often have specific policies regarding concierge medicine, which can be a major factor in deciding whether to switch to this type of care. Some insurance plans may cover a portion of the costs, while others may not cover it at all.

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Insurance coverage for concierge medicine can be confusing, but it's not a one-size-fits-all situation. Some concierge practices are out of network with insurers, leaving patients to cover the full cost of a visit or procedure, although they may provide documentation for reimbursement.

Insurance companies generally do not cover the membership fee, which is a monthly or annual fee to participate in a concierge medical practice. This fee is considered a non-medical service and is not covered by insurance.

Annual physicals and well-checks are generally covered, but insurance companies may deny certain services that are part of a wellness check. Some concierge practices, like Dedication Health, offer annual physicals at no charge to their members.

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Most patients are familiar with how medical insurance works, but let's break it down. The care doctors provide is a service, and the cost for that service is split between the patient's insurer and the patient.

A common coinsurance breakdown is 20/80, where patients pay 20 percent of covered services, like a $20 copayment for a standard 15-minute primary care appointment. Insurance will pay the doctor $80 in this case.

Patients may pay a fixed copayment, such as $50 a visit, versus a percentage of the overall bill. This can be confusing, but it's essential to understand the terms of your insurance plan.

If you have a deductible, you'll need to meet it before your insurance kicks in. This can vary depending on your plan, so be sure to check your policy.

Doctors must be credentialed or "in network" with the carrier to receive payment from the insurer. This ensures that the care you receive is covered under your insurance.

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In many concierge medical practices, patients pay a copayment or coinsurance and the doctor bills insurance for the remainder. However, concierge practices also charge additional fees.

Those fees may cover ancillary services provided by the doctor or they may merely exist just to be a member of the doctor's panel. Some concierge practices are out of network with insurers and patients cover the full cost of a visit or procedure.

The concierge doctor's practice provides documentation to the patient so they can seek reimbursement. Other concierge practices accept no insurance and operate direct primary care practices.

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MDVIP-affiliated primary care practices offer similar convenience benefits as many concierge practices, but MDVIP goes beyond by offering a program focused on preventive care.

The membership fee in an MDVIP-affiliated practices pays for the MDVIP Wellness Program, which includes services not typically covered by insurance or Medicare.

Most doctors in the national network accept private insurance and Medicare for sick visits and follow ups. You can find out if an MDVIP-affiliated doctor takes your insurer by calling their office.

Concierge medicine membership fees can be a significant barrier for many patients, with most fees ranging from $2,000 to $5,000 per year.

Some concierge practices charge as high as $10,000 yearly, although this is anecdotal evidence. Your location and doctor's experience can also impact the cost.

PartnerMD memberships range from $2,500-$3,000 per year for adults, which breaks down to $208-$250 per month.

The cost of concierge medicine is not just a one-time fee, but rather an annual retainer that covers personalized services and extra time with your doctor.

The fee typically doesn't include hospital visits, specialist care, or emergency services, so it's essential to understand what's covered and what's not.

To put the cost into perspective, some patients use HSA or FSA funds to help cover the costs, making the investment more manageable.

Here's a rough estimate of the costs involved:

Keep in mind that these are just estimates, and actual costs may vary depending on your location and doctor's experience.

Annual physicals and well checks are generally covered, but insurance companies often deny regular wellness check components due to loopholes in the Affordable Care Act.

Insurance companies don't care if a procedure was performed by a concierge doctor or a traditional one, as long as the doctor was in-network and the procedure was given a specific code.

Concierge medical practices can be in-network, but many don't involve themselves with insurance, leaving patients to bill their insurance on their own. Some concierge practices are even out of network with insurers, requiring patients to cover the full cost of a visit or procedure.

Annual physicals and well checks are generally covered, but it's essential to understand the nuances. Insurance companies often deny coverage for services that are part of a wellness check, despite the Affordable Care Act's intention to provide free annual physicals.

Dedication Health, on the other hand, includes an annual physical at no charge to its members, cutting through the red tape that insurance companies may create. This is a refreshing approach that prioritizes patients' needs.

In concierge medical practices, patients often pay a copayment or coinsurance, and the doctor bills insurance for the remainder. However, these practices also charge additional fees, which may cover ancillary services or simply be a membership fee.

Some concierge practices are out of network with insurers, requiring patients to cover the full cost of a visit or procedure. But these practices still provide documentation to help patients seek reimbursement.

Some concierge medical practices don't involve themselves with insurance at all, leaving you to bill your insurance on your own.

If the doctor is out of network, they may or may not provide coverage, so it's essential to check with the practice before joining.

Many concierge medical practices accept fewer insurance carriers than traditional practices, so it's crucial to check your insurance coverage before joining.

In some cases, concierge practices are out of network with insurers, and patients cover the full cost of a visit or procedure.

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Concierge practices that are in-network with your insurance company will typically bill insurance for the remainder after a copayment or coinsurance, just like a traditional practice.

If a concierge practice doesn't accept your insurance, they might charge an additional fee for members of their practice whose insurance they don't accept.

Here's a breakdown of how concierge practices might handle insurance for various procedures:

Traditional primary care is a traditional approach to healthcare where patients receive routine check-ups, vaccinations, and screenings from their primary care physician.

Concierge medicine and traditional primary care differ mainly in their approach to patient care and accessibility, with traditional primary care being more accessible to a wider population.

In traditional primary care, patients typically have a long wait time to see their doctor, often ranging from several weeks to several months.

This approach to healthcare often relies on a one-size-fits-all model, where patients are treated in a group setting rather than individually.

Traditional primary care physicians usually have a large patient load, making it challenging for them to provide personalized attention to each patient.

However, traditional primary care is often more affordable and widely available, making it a viable option for many people.

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