Short answer: You can pay a doctor directly, but Medicare will not pay the membership fee. Medicare does not cover concierge membership fees, and its pages do not say it pays direct primary care fees. If the doctor has opted out of Medicare, Medicare generally pays nothing for that doctor's care except in emergencies. Get free help before you sign.
Medicare.gov says Medicare does not cover membership fees for concierge care, and you pay all costs for services Medicare does not cover. Its page on concierge care does not mention direct primary care by name. We found no official Medicare statement about direct primary care fees, so ask both the practice and Medicare before you pay.
A doctor can choose to opt out of Medicare, which means the doctor does not bill Medicare at all. Medicare.gov says Medicare will not pay for items or services you get from a provider who opts out, except in emergencies. It also says providers opt out for a minimum of 2 years. You can ask the practice whether the doctor has opted out.
If your doctor has opted out, Medicare.gov says you may have to pay up front or set up a payment plan through a private contract. A private contract is a written agreement between you and the doctor. Medicare.gov says Medicare will not pay for any service you get from this doctor, even if it is a service Medicare normally covers. A medical journal article from the American Academy of Family Physicians says the contract must be in writing and signed by both sides, and the doctor must give you a copy before services begin.
The American Academy of Family Physicians article also explains that a doctor's opt-out lasts two years and renews on its own unless the doctor ends it. It says an opted out doctor may set their own fees but may not send claims to Medicare. Urgent and emergency care can be an exception, and in those cases the doctor may bill Medicare.
Some doctors do not accept Medicare as full payment but have not opted out. Medicare.gov says you might have to pay the full amount at the time of service, and these doctors can charge you more than the Medicare-approved amount. In many cases the charge cannot be more than 15% above that amount. This is a different situation from an opt-out, so ask the practice which one applies to your doctor.
Medicare.gov suggests contacting your State Health Insurance Assistance Program (SHIP) for help before signing a private contract with any doctor. SHIP is a state program that gives free counseling about Medicare. We could not confirm from the official pages how your other Medicare coverage works while you are a member of a practice. Ask the practice and SHIP to explain that in writing.
You can find a direct-pay doctor near you and ask these questions.
Medicare.gov says it does not cover membership fees for concierge care. We found no official statement that says Medicare pays a direct primary care fee.
It is a written agreement used when a doctor has opted out of Medicare. Medicare.gov says Medicare will not pay for services from that doctor, even ones it normally covers.
