Does Medicare work with concierge medicine services?

Concierge medicine, also known as direct primary care, is an alternative to the typical “fee-for-service” doctor’s office. Rather than pay a fee each time you visit your physician, concierge services require a membership fee.

This new type of practice has been in the news lately, so you may be wondering if it’s a good fit for you. Normally, a visit to the doctor means a long wait for a short visit. The office charges you a copay and bills the remainder of the visit to your insurance provider. A concierge service, on the other hand, charges a monthly or annual membership fee, and limits the number of patients who can join.

This translates to short waits and same-day appointments in some cases, and appointments can be as long as necessary, sometimes 60 minutes or more, to allow for a thorough visit. There are no copays or insurance deductibles for the visit.

Concierge services work well for people who go to the doctor frequently, and can cover things such as office visits, wellness exams, basic office procedures, most in-office tests and injections, and 24/7 access to your doctor. They do not usually cover hospitalizations, evaluations by other physicians or specialists, emergency room visits, prescription medications, outside lab work, pathology services, radiology, or physical therapy, although some offices do in fact cover some of these. For example, Dr. Goetter’s office in Decatur does cover some services, like an EKG or CT scan.

What if I’m on Medicare?

First, it’s important to note that a service using this business model will not bill your insurance. Typically a doctor would bill Medicare for your visit. Medicare Part B covers 80% of approved physician services, outpatient care, tests and supplies, after a $166 deductible. A Medicare Supplement insurance plan would normally kick in after that, but Medicare doesn’t factor into this equation, unless you’re referred to another physician or specialist. The membership fee for concierge service must be paid by you.

If Medicare doesn’t pay, then is it worth using a direct primary care or concierge service? That depends on a couple of things:

• Do you visit your primary care physician frequently?
• Do you value the convenience enough to pay for it?
• Can you afford the membership fee?

If paying $1200-$2000 per year is something you’re comfortable with, and you want to be able to get in to see your doctor within 24 hours, or even have the option to call or email him, this may be a good fit for you. Be aware that you do still need insurance to cover the items that aren’t included in your membership.

If you’re considering a membership, be sure to check with providers to see exactly what’s included, and what’s not, since it varies. In the Decatur area, you currently have 2 local options:

Priority Health Family Medicine
Dr. Timothy A. Miller and Dr. Kristin Newcome
5160 North Hickory Point Frontage Road
Decatur, IL 62526
217-330-9788
http://www.priorityhealthmd.com/

DMH Signature Health
Dr. Stephen R. Goetter
389 W. Weaver Road, Suite 100
Forsyth, IL 62535
217-876-5390
https://www.dmhcares.com/find-a-doctor/dmh-signature-health/

If you’re unclear on what Medicare will or will not cover, please contact us!‍