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Insurance Contracts and Membership Fees: What to Check Before You Charge
Most concierge conversations start with Medicare. For a physician who keeps billing commercial insurance, the network contracts already signed may matter just as much. This brief walks through the contract terms that decide whether a membership fee is allowed and what insurers and state regulators have put in writing about it. It ends with a pre-launch checklist to work through with counsel.
New in October 2026. A companion to Brief No. 33 (Medicare) and Brief No. 37 (practice models).
Start here: the questions this brief answers
Tap a question for the short answer, then jump to the evidence.
If you stay in insurance networks, your contracts set rules for your membership fee. Most network contracts include a hold-harmless promise: for covered services, you accept the plan’s payment plus the patient’s cost sharing as payment in full. Some insurers go further. AmeriHealth and Independence Blue Cross both told network physicians that a mandatory annual fee for covered services breaks the provider agreement and can lead to removal from the network; a Rhode Island Blue Cross policy sets similar limits. The two Pennsylvania-area notices list well visits, care coordination, specialist referrals and 24/7 phone access as covered care. New Jersey regulators allow retainer fees by network physicians only for services beyond the plan, with disclosure and continuity safeguards. Medicare’s assignment rule draws a similar line, and Medicare Advantage contracts add their own hold-harmless terms. In CMT’s reading, the No Surprises Act’s billing protections are aimed at emergency and facility-based care, not an office membership fee, though its good faith estimate rules may reach some self-pay services. Before you launch, put your questions to each payer in writing and have a healthcare attorney review the whole plan.
Does my insurance contract allow a membership fee?
It depends on the contract. Many network contracts require you to accept the plan’s payment plus cost sharing as payment in full for covered services, and some insurers explicitly prohibit or restrict concierge fees. The answer sits in your contract, its amendments, the provider manual it incorporates and your state’s law.
Go to the full answer ↓What counts as a “covered service”?
The plan and the contract define it, not the practice. Two insurer notices CMT reviewed list well visits, care coordination, specialist referrals and 24/7 telephone access as covered services. Many membership fees promise exactly that.
Go to the full answer ↓Have state regulators weighed in?
Some have. New Jersey set four safeguards for network physicians who offer retainer services in 2012, and Maryland’s insurance regulator described in 2009 when a retainer practice might be doing the business of insurance. Rules vary by state.
Go to the full answer ↓What about Medicare and Medicare Advantage?
A participating physician agrees to accept Medicare’s approved amount as full payment for covered services, so a fee may cover only what Medicare does not. Medicare Advantage contracts must also bar providers from billing enrollees for amounts the plan owes.
Go to the full answer ↓Does the No Surprises Act apply to my fee?
Its balance billing protections are built around emergencies and facility-based care, plus air ambulances. In CMT’s reading that does not describe an office membership fee. Its good faith estimate rules for uninsured and self-pay patients may still apply to some services. Ask counsel.
Go to the full answer ↓What should I do before I launch?
Work through the 12-point checklist in Part 5 with your attorney. It starts with pulling every contract and manual and mapping each item in your fee against covered services.
Go to the full answer ↓The promise you already signed
A physician who joins an insurance network signs a contract, and almost every such contract contains a promise about what the physician may collect from the plan’s members. That promise, not the membership agreement the practice writes later, is usually where the review should start.
The model language most states draw on comes from the National Association of Insurance Commissioners. Its network adequacy model act asks every carrier-provider contract to include a hold-harmless clause: the provider may not bill or seek payment from a covered person for covered services, apart from the plan’s own cost sharing, such as copayments and deductibles.1 Policy and Law The same clause lets providers charge for “uncovered services delivered on a fee-for-service basis.”1
That exception matters, and so does its wording. A membership fee is usually a periodic charge, not a fee for a single service. CMT’s reading: whether a periodic fee fits a fee-for-service exception depends on how your state and your contract phrase it, and that is a question for counsel, not a template. States adopt model acts in different forms. Read the model as a guide to what to look for in your own contract.
Attorneys who work with membership practices raise the same point. Writing for CMT’s legal commentary page in 2025, attorney Jonna D. Eimer noted that “some payor agreements may specifically prohibit any patient fee for membership in a practice,” and that some practices have asked their commercial payers to review and approve their patient agreements and fees before converting.5 Practice Insight A 2024 law firm checklist adds that breaching network terms “could jeopardize your participation status.”6 Practice Insight
Write down what the patient gets for the fee that the plan does not already pay you to provide. If the list comes down to faster access to the same covered care, expect some of your payers to object.
What insurers and regulators have actually said
CMT looked for documents in which a state regulator or an insurer addressed membership or retainer fees directly. These are the ones it could open and confirm. They are examples, not a survey: other insurers may allow these fees, or never mention them.
| Source | What it says | What to check in your practice | Evidence type |
|---|---|---|---|
| New Jersey Department of Banking and Insurance, Bulletin 12-02 (2012) | Network physicians may offer retainer services without being considered discriminatory if four safeguards hold: members are not charged more than their cost sharing for covered services and retainer payments buy only services beyond the plan, clearly described; retainer-only physicians do not count toward network adequacy; directories identify limited practices; and existing patients keep continuity-of-care rights without paying a retainer.2 | If you practice in New Jersey, whether your fee buys only non-covered services, and how your plans list you | Policy and Law |
| Maryland Insurance Administration report (2009) | Offers a framework for when a retainer practice may be engaged in the business of insurance, such as unlimited services for a fixed fee, no patient caps, fees above market value or no pro-rated refunds. Urges physicians who contract with insurers or Medicare to review “the statutory, regulatory and contractual prohibitions on balance billing.”7 | Whether what your fee promises could look like insurance (see Brief No. 44), and your balance billing terms | Policy and Law |
| AmeriHealth provider notices (2015, 2016) | A mandatory annual payment from members “violates the terms of your AmeriHealth Professional Provider Agreement.” Providers must accept AmeriHealth’s payment as payment in full for covered services; a violation can lead to termination from the network.8 | Whether your insurer has a similar notice or manual section | Industry Research |
| Independence Blue Cross provider news (2022) | Charging members a set fee, “such as an annual membership fee or other surcharge,” to keep receiving covered services violates the provider agreement. The policy was added to the provider manual in November 2022.9 | Manual updates that may bind you without a new signature | Industry Research |
| Blue Cross & Blue Shield of Rhode Island payment policy (updated 2023) | Retainer or access fees are not covered and may not be applied to covered services. Optional fees for services beyond what the plan covers must be confirmed in writing as voluntary, and patients who do not pay must get the same care and access. Existing providers give 90 days’ written notice; retainers may never be charged to Medicare Advantage members.3 | Notice duties and voluntariness wording, plus any separate rule for Medicare Advantage members | Industry Research |
Two of the insurer notices define covered services broadly. AmeriHealth lists well-patient visits, 24/7 emergency telephone consultation, treatment of acute conditions, coordination of medically necessary care and specialist referrals, and adds that longer visits and wellness-type services belong to covered care as well.8 Independence Blue Cross lists the same core services and requires 24/7 telephone access.9 Industry Research
Many membership practices describe their value in nearly those words.
Older legal commentary makes the same point from the physician’s side. A 2009 Maryland law firm article reminded physicians converting to a boutique model that they remain bound by “the contractual obligations found in their existing participating provider agreements” and by state HMO balance billing rules.10 Practice Insight
A fee can be lawful under state law and still breach a network contract. The two questions are separate. A payer’s objection is usually not a fine but a termination notice, which can cut off a large share of revenue at once. That is CMT’s editorial reasoning from the documents above, not a legal standard.
Medicare, Medicare Advantage and the No Surprises Act
Medicare has its own version of the payment-in-full rule. For physicians who also see Medicare patients, a fee may buy what the program does not cover, never a covered service.
A physician who accepts assignment agrees to accept Medicare’s approved amount as the full charge and to collect only the difference between that amount and Medicare’s payment, meaning deductibles and coinsurance.11 In 2004, the HHS Office of Inspector General warned that asking for any other payment for a covered service violates the assignment agreement; in the case it described, a $600 annual contract included services the OIG alleged Medicare already covers, such as care coordination and “extra time” spent with patients.4 A 2007 settlement reported by a law firm required a physician to pay $106,600.12 Brief No. 33 covers this in depth.
Physicians who do not accept assignment on a claim are still limited to the “limiting charge” for covered services and can be penalized for overcharging.4
Opting out requires an affidavit and a signed private contract with every Medicare patient, and the period lasts two years and renews automatically.13
Federal rules require each Medicare Advantage organization’s provider contracts to prohibit providers “from holding any enrollee liable” for fees that are the plan’s legal obligation.14 One insurer’s policy goes further: “Under no circumstances should a Medicare Advantage Plans member be charged a retainer fee.”3 CMT’s reading: treat each Medicare Advantage contract as its own review.
Since 2022, federal surprise billing protections cover emergency care and out-of-network air ambulance services. They also reach non-emergency care from out-of-network providers working at in-network facilities.15 Training material from CMS names in-network hospitals and ambulatory surgical centers as examples of those facilities.16 CMT’s reading: a membership fee charged by an in-network office practice does not fall in those categories, so the act is not the main constraint; your contract and state balance billing law are. State surprise billing laws can be broader.
The same law requires providers to give uninsured or self-pay patients a good faith estimate for scheduled items and services, with a dispute process if the bill is at least $400 more than the estimate.15,
These figures describe direct primary care (DPC), not concierge medicine. DPC usually operates outside insurance billing at lower monthly fees. They are shown here, separately, for context only and should not be read as concierge data.
Washington’s direct practice law shows how a state can draw the line for DPC. A direct practice that complies with the chapter is not an insurer. It may not submit claims to a carrier, or hold a participating provider contract, for services covered by its direct agreements, and carriers may not count it toward network adequacy for those services. Contracts with carriers for other purposes are still allowed.18 These rules govern DPC, not concierge practices that bill insurance.
Where membership fees collide with contracts
The same patterns turn up again and again in the documents CMT reviewed. Red cards are arrangements the sources warn against. Teal cards are approaches a regulator or insurer has described as workable when its conditions are met, and amber falls in between.
A mandatory fee to stay in the practice
This is the arrangement all three insurer documents target: members must pay to keep receiving covered care from a network physician.8,
Under those policies, the options are to make any fee optional and limited to non-covered services, or to leave the network.
Access sold as the product
When the fee is marketed as faster appointments, longer visits, after-hours phone lines or a direct cell number, it can describe services some insurers already treat as covered.8,
Messaging and virtual care
One 2026 law firm article calls unlimited messaging a gray area because insurers pay for e-visits and virtual check-ins.19 Practice Insight That is one firm’s view. Check how each of your plans pays for portal and virtual care.
Administrative and convenience fees
A specialty society’s coding guidance says extra administrative costs for Medicare patients are generally absorbed by the practice. For commercial plans it points practices to their participating contracts, and it warns that state law can govern convenience fees too.20 Practice Insight
“The devil is in the contract.” Maryland Insurance Administration, 2009
The regulator was describing membership agreements and the business of insurance.7 CMT applies the line to payer contracts as editorial reasoning.
CMT survey data that would help here: among concierge practices that kept billing commercial insurance, how many notified payers before launch, and how many payers approved, objected, asked for changes or ended the contract. Report sample size, dates, recruitment and the concierge and DPC respondents separately.
Editor: replace this box with CMT survey results (with sample size, dates and recruitment method) before publishing, or delete it.
The pre-launch contract review checklist
Use this list to organize the review with your attorney and billing lead. It covers topics, not answers, and finishing it does not mean a fee is compliant. Nothing is saved or sent anywhere.
Before you charge a membership fee: which of these are done?
A planning aid only. Not legal advice and not a compliance determination.
- Does our agreement or your provider manual restrict membership or retainer fees?
- Which of these services do you treat as covered: extended visits, care coordination, after-hours phone access, portal messaging, annual wellness exams?
- What notice do you require before we change our practice model or close our panel, and how will our directory listing change?
- Do your answers differ for your Medicare Advantage or Medicaid products?
For attorney views on these questions, including commentary on commercial payer agreements, see CMT’s Legal Experts’ Commentary.5 Brief No. 33 covers Medicare in depth, and Brief No. 37 compares the practice models.
Read what you signed
Know the payment-in-full clause and the covered-services definition in every network contract before you design a fee.
Design the fee around gaps
Build the fee from services and amenities no plan pays for, written down item by item, and keep membership revenue separate from claims.
Ask before you announce
Put your questions to each payer and your attorney in writing, then tell patients plainly what the fee buys and what insurance still covers.
How this brief was built
CMT searched for official guidance from state insurance regulators and attorneys general on retainer and concierge fees, published insurer policies on membership or access fees, federal Medicare and Medicare Advantage rules, the No Surprises Act, and law firm commentary. Every source cited here was opened and checked in October 2026. Insurer notices are labeled Industry Research because they are company documents. Law firm articles are labeled as law firm commentary and describe one firm’s view. CMT found usable state documents from New Jersey and Maryland; it did not find published guidance on this question from Massachusetts or from a state attorney general, and those are not cited. Washington’s statute appears only in the DPC box because it governs direct practices, a different model.
This brief is about concierge practices that keep billing insurance. Direct primary care, which usually does not bill insurance, is kept separate and appears only in a walled-off box. No DPC figures appear in this brief. The checklist in Part 5 lists topics to review. It does not test compliance and gives no legal verdict. Because this is a legal topic, CMT recommends independent review by a healthcare attorney licensed in your state before relying on any part of it.
How to read the evidence types
Every key finding is labeled by evidence type. Labels describe the type of evidence, not its value. Each type answers different questions. Funding is disclosed on every source.
Randomized trials and systematic reviews.Best for cause and effect.
Large observational studies and government data.Best for trends at scale.
Surveys, smaller studies and expert consensus.Best for real-world experience.
Company-sponsored or company-reported data that is not peer-reviewed.Best for early signals and operating data.
Statutes, regulation and official guidance.Best for what is required.
What we don't know
- How many commercial insurers restrict membership fees, and how many allow them. Many provider manuals are behind login screens, and no public survey exists.
- How often insurers have actually removed concierge physicians from networks. CMT found policies, not enforcement data.
- Which states have adopted hold-harmless language like the NAIC model, and how each words its exception for non-covered services.
- Whether a periodic membership fee counts as a fee for “uncovered services delivered on a fee-for-service basis” under model hold-harmless language. CMT found no regulator guidance on that question.
- Whether, and when, good faith estimate rules apply to non-covered services sold to commercially insured members.
How to cite this brief
External review: this brief has not yet been reviewed by an outside expert. When review is complete, the reviewer is credited by name above with any conflicts of interest, and the version number is updated. Reviewers check accuracy and fairness; CMT is responsible for the final content.
Corrections policy: when an error is identified, CMT corrects it in the open and updates the version number above. Send corrections to the editor through conciergemedicinetoday.net.
Related CMT Research Briefs
References
- National Association of Insurance Commissioners. Health Benefit Plan Network Access and Adequacy Model Act (Model 74), Section 6B, hold harmless provision. NAIC Model Laws, Regulations, Guidelines and Other Resources, 4th Quarter 2015. content.naic.orgFunding: not stated (model law published by the National Association of Insurance Commissioners)
- New Jersey Department of Banking and Insurance. Bulletin No. 12-02: Provision of non-covered services by limited-panel network physicians. Thomas B. Considine, Commissioner. January 9, 2012. nj.govFunding: state (New Jersey Department of Banking and Insurance publication)
- Blue Cross & Blue Shield of Rhode Island. Physician Concierge Services (payment policy). Effective July 1, 2006; last updated July 5, 2023. bcbsri.comFunding: industry (Blue Cross & Blue Shield of Rhode Island payment policy)
- HHS Office of Inspector General. OIG Alert: charging Medicare beneficiaries for services that are covered (assignment violations). March 31, 2004. hhs.govFunding: federal (HHS Office of Inspector General publication)
- Concierge Medicine Today. Legal Experts' Commentary: the rules differ by model, and by what you add (CMT editorial summary of public sources). October 2026. conciergemedicinetoday.netFunding: Concierge Medicine Today (self-published; no outside funder) CMT original
- Holt D. A concierge medicine legal checklist: key considerations for transitioning your practice. Holt Law. June 14, 2024 (modified April 15, 2025). Law firm commentary. djholtlaw.comFunding: not stated (law firm analysis)
- Maryland Insurance Administration. "Retainer" or "Boutique" or "Concierge" Medical Practices and the Business of Insurance (Report MIA-2008-12-002). January 2009. insurance.maryland.govFunding: state (Maryland Insurance Administration publication)
- AmeriHealth (AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey). Concierge medical practices prohibited as a participating provider (professional provider notice). December 30, 2015; reminder issued June 1, 2016. provcomm.amerihealth.comFunding: industry (AmeriHealth provider communication)
- Independence Blue Cross. Concierge medical care violates the terms of your provider agreement with Independence Blue Cross (provider news). December 20, 2022. provcomm.ibx.comFunding: industry (Independence Blue Cross provider communication)
- Rosen BF. Boutique medicine: legal pitfalls. Gordon Feinblatt LLC, Mid-Atlantic Health Law Topics. June 22, 2009. Law firm commentary. gfrlaw.comFunding: not stated (law firm analysis)
- Code of Federal Regulations, Title 42, section 424.55: Payment to the supplier (conditions of accepting assignment). Electronic Code of Federal Regulations, current as of October 2026. www.ecfr.govFunding: federal (federal regulation)
- Farrell Fritz. Concierge medicine: Medicare compliance is still a consideration. September 19, 2017. www.farrellfritz.comFunding: not stated (law firm analysis)
- Noridian Healthcare Solutions (Medicare Administrative Contractor). Opt-out period, renewal, and cancellation. med.noridianmedicare.comFunding: federal (Medicare Administrative Contractor guidance issued under contract with CMS)
- Code of Federal Regulations, Title 42, section 422.504(g): Medicare Advantage contract provisions, beneficiary financial protections. Electronic Code of Federal Regulations, current as of October 2026. www.ecfr.govFunding: federal (federal regulation)
- Centers for Medicare & Medicaid Services. No Surprises Act: Overview of rules and fact sheets. Last modified August 18, 2026. www.cms.govFunding: federal (Centers for Medicare & Medicaid Services publication)
- Centers for Medicare & Medicaid Services. The No Surprises Act: An overview for assisters, advocates, agents and brokers. February 2022. www.cms.govFunding: federal (Centers for Medicare & Medicaid Services training material)
- Centers for Medicare & Medicaid Services. What is considered "health insurance"? Determining when uninsured (or self-pay) good faith estimate rules apply (fact sheet). Undated. cms.govFunding: federal (Centers for Medicare & Medicaid Services publication)
- Revised Code of Washington, chapter 48.150: Direct practices (sections 48.150.010, .040 and .060). Washington State Legislature. app.leg.wa.govFunding: not stated (state statute)
- Holt D. The legality of "convenience fees" and "membership dues" in medical practices. Holt Law. March 5, 2026. Law firm commentary. djholtlaw.comFunding: not stated (law firm analysis)
- American Academy of Ophthalmology. Charging convenience fee (practice management Q&A, from Fundamentals of Ophthalmic Coding). June 9, 2023. aao.orgFunding: not stated (American Academy of Ophthalmology practice management content)
- American Medical Association. Code of Medical Ethics Opinion 11.2.5: Retainer Practices. code-medical-ethics.ama-assn.orgFunding: not stated (American Medical Association ethics policy)
Educational and informational only. This CMT Research Brief does not constitute medical, legal, tax, financial, accounting or other professional advice, and it does not create a professional relationship of any kind. Statements about laws, regulations, tax rules and payer policies are general, may not reflect the rules in your state, and can change after publication. Consult a qualified attorney, accountant, tax adviser, compliance professional or licensed clinician before acting on anything here.
Independence. Concierge Medicine Today is an independent publication. It does not accept payment for favorable coverage, and it does not favor one practice model over another. Company names and products are mentioned for context only and are not endorsements. Funding is disclosed for every source in the reference list.
Accuracy. CMT verifies figures against their original or best available sources at the time of publication. Where a figure is an estimate, an inference or a company-reported number, the brief says so. This content is not without possible error or omission.
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