Concierge Medicine: Retainers, Coverage, and Medicare

For a Medicare patient, the most important fact about a concierge doctor’s annual fee is not its size but whether the doctor still bills Medicare. Two quite different arrangements can sit behind the same calm reception room. In one, the physician bills Medicare for covered care and charges the retainer only for what Medicare does not pay for. In the other, the physician has left Medicare, your care runs under a private contract, and Medicare pays nothing for that doctor’s services.

The choice of a doctor often returns to you after a loss. What follows explains how retainer practices are built, what federal rules let a doctor charge a Medicare patient, and how to judge access, hospital care, specialists and records before you commit. If you are under 65 and were covered through your husband’s employer, read Health Insurance After a Spouse Dies first; its deadlines may already be running.

What a retainer practice sells

Concierge, boutique, retainer and membership are names practices choose for themselves; for Medicare, what counts is the doctor’s billing status. Beneath the names sits a periodic fee, paid monthly or yearly, for a smaller and more available practice. A settlement described in guidance from the Department of Health and Human Services’ Office of Inspector General (OIG) lists a familiar menu: an annual physical, same- or next-day appointments, dedicated staff, around-the-clock physician availability, help with prescriptions, and expedited, coordinated referrals.

Some practices, often called direct primary care, take the fee as their only payment. Others also bill insurance, including Medicare, for covered visits and tests. Either way, the fee buys availability, not coverage. State law on these agreements varies, so ask which state’s rules govern the contract.

Three ways a doctor can stand with Medicare

Medicare.gov describes three positions, each with a different bill:

1. Participating. The doctor accepts assignment, taking the Medicare-approved amount as full payment for covered services and submitting the claim. You owe only the deductible and coinsurance; the OIG notes that once the deductible is met, Medicare pays 80 percent of the fee-schedule amount and you pay 20 percent.
2. Non-participating. The doctor bills Medicare but accepts assignment only case by case. You may pay in full at the visit, and the doctor may charge more than the approved amount, in many cases by no more than 15 percent, a ceiling called the limiting charge.
3. Opted out. The doctor has left Medicare, which pays nothing for that doctor’s items or services except in emergencies. Covered care for Medicare patients is given only under private contracts.

A retainer can sit on top of any of the three. The first two leave Medicare paying its share of your covered care. The third does not, and Medicare.gov warns that a Medigap policy pays nothing for services under a private contract.

What a retainer may lawfully buy

On March 31, 2004, the OIG issued an alert reminding participating physicians that they may charge Medicare patients for items and services Medicare does not cover, and may collect deductibles and coinsurance, but that requesting any other payment for covered services exposes them to substantial penalties and exclusion from federal health programs. It described a physician who asked patients for a $600 annual fee for services he called noncovered, among them “coordination of care with other providers,” “a comprehensive assessment and plan for optimum health,” and “extra time.” The OIG alleged that at least some were already covered; he paid a settlement and stopped offering the contracts.

The OIG’s guidance for new physicians is blunter: an “access fee” or “administrative fee” that simply allows patients to obtain Medicare-covered services constitutes double billing. In the settlement whose menu appears above, a physician paid $107,000 to resolve potential liability because, the OIG alleged, some of the services his annual fee listed were already covered by Medicare.

A retainer may buy what Medicare does not cover; it may not buy a second time what Medicare already pays for.

The CMS manual adds a protection. Outside a proper opt-out, an agreement in which a Medicare patient waives the claim-filing rules or the limits on charges has no legal force, and an agreement to exclude services from Medicare coverage is ineffective. Medicare’s dedicated concierge-care guidance also says that when an assignment-accepting doctor expects Medicare not to cover an item or service, the doctor must give you an Advance Beneficiary Notice of Noncoverage that identifies the service and explains why payment may be denied. The penalties for double billing fall on the physician, but the practical defence is yours: ask for a written list of what the fee buys, which items the practice also bills to Medicare, and when it will use an advance notice.

When the doctor has left Medicare

Once a doctor opts out, the arithmetic changes. Medicare won’t pay for any service from that doctor, even one it would otherwise cover. Under the CMS manual, Medicare Advantage plans may not pay for an opted-out doctor’s covered services either, apart from the emergency exception described below.

Opting out is all or nothing: a doctor cannot opt out for some Medicare patients or services and not others. It lasts at least two years, and affidavits signed on or after June 16, 2015 renew automatically every two years unless the doctor cancels.

The private contract must be in writing, in print large enough to read, and signed by you both. It must say whether the doctor has been excluded from Medicare; state that you accept full responsibility for payment, that Medicare’s charge limits do not apply, that you will not submit a claim, and that Medigap plans do not pay; and give the dates of the current two-year opt-out period. You must receive it before services begin; it cannot be signed while you need emergency or urgent care; and it is renewed for each two-year period. It must also acknowledge that you remain free to see doctors who have not opted out.

Tests, hospital stays and other services an opted-out doctor orders can still be paid by Medicare, if the doctor meets the ordering requirements and whoever furnishes the service has not also opted out. The emergency exception, which lets an opted-out doctor bill Medicare for emergency or urgent care, applies only to patients who have not signed a private contract with that doctor. And Medicare.gov suggests calling your State Health Insurance Assistance Program before you sign.

Access, the hospital and the specialists

The fee is meant to buy availability, so test it first. Ask what “same-day” means on a Friday afternoon, who answers when the doctor is away, and how many patients the doctor carries; that number, more than the brochure, measures availability.

Ask where the doctor holds hospital privileges, whether the doctor will see you there or hand you to the hospital’s own team, and how information returns to the practice. Ask which specialists the practice favours, whether they accept Medicare, and whether a “coordinated referral” means a call from your physician or a list of names. If you spend long periods abroad, Medicare there is a separate question; Medical Cover Abroad After 65 sets out where it stops.

What the 2025 tax law changed, and what it did not

The One Big Beautiful Bill Act touches this subject only if you hold a health savings account. From January 1, 2026, the IRS says, an otherwise eligible person in a qualifying direct primary care arrangement may contribute to an HSA and pay the periodic fee from it tax-free. Enrolment in Medicare ends HSA contributions, though an existing balance can still be spent on qualifying expenses, so for a Medicare patient only the second half can apply. The definition is narrow: primary care from primary care practitioners, with a fixed periodic fee as the sole compensation. For the contribution rule, the fee must also not exceed $150 a month for one person, or $300 for an arrangement covering more than one, in 2026. IRS Notice 2026-5 states that an arrangement which charges a membership fee but bills separately for services, “through insurance or otherwise,” does not qualify, which, on its face, leaves out a retainer practice that bills Medicare for its members’ care. The notice does allow a qualifying arrangement’s doctors to bill separately for services offered outside it to members and non-members alike, so the answer turns on how the practice is built. Ask your tax adviser whether any part of a retainer is deductible.

Keeping your records portable

The relationship may end for ordinary reasons: a higher fee, a move, a retirement. Under the federal privacy rule, a provider it covers (broadly, one that handles insurance transactions such as claims electronically; a practice that bills no insurance may fall outside it) must act on your request for access within 30 days, with one extension of no more than 30 days if it explains the delay in writing. It must supply records it keeps electronically in the electronic form you ask for, if readily producible, send the copy directly to a person you designate on a signed, written request, and charge no more than a reasonable, cost-based fee for labour, supplies and postage.

Better still, do not wait for a departure. Ask for an electronic copy of your full record once a year, keep a one-page summary of diagnoses, medications, allergies and clinicians, and have the agreement say who will hold your records if the practice closes, is sold, or the doctor dies. A Health Checkup Plan for the Year After Your Spouse Dies suggests what to bring to a new physician.

Questions to ask before you sign

1. Is the doctor participating, non-participating, or opted out of Medicare, and will the practice confirm it in writing?
2. Exactly which services does the fee cover, and does the practice also bill Medicare for any of them?
3. If the doctor has opted out, what would a typical year of care cost in all?
4. Who answers after hours, at weekends and when the doctor is away, and how quickly?
5. At which hospitals does the doctor hold privileges, and will the doctor see you there?
6. Which specialists does the practice refer to, and do they accept Medicare?
7. What is refunded if you leave mid-year, or if the doctor retires or the practice closes?
8. How will you receive a complete electronic copy of your records, and at what cost?
9. Does any answer change if you have Medicare Advantage rather than Original Medicare with Medigap?

This article provides general U.S. educational information and is not medical, legal, insurance, or tax advice. Confirm current rules with Medicare, and review any contract with a qualified adviser or your State Health Insurance Assistance Program before you sign.