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Last Modified: 2/17/2021 Location: FL, PR, USVI Business: Part B

Information on opting out of Medicare

Please view the following information applicable to providers who wish to opt-out of Medicare.

Private contracts/opting out of Medicare

Eligible practitioners who want to opt-out must file an affidavit pdf file with Medicare in which they agree to opt-out of Medicare for a period of two years and to meet certain other criteria. In general, the law requires that during that two-year period, eligible practitioners who have filed affidavits opting out of Medicare must sign private contracts pdf file with all Medicare beneficiaries to whom they furnish services that would otherwise be covered by Medicare, except those who are in need of emergency or urgently needed care. They cannot sign such contracts with beneficiaries in need of emergency or urgent care services. Moreover, eligible practitioners who opt-out cannot choose to opt-out of Medicare for some Medicare beneficiaries but not others; or for some services and not others.
The policy of the opt-out affidavit is in the Internet Only Manual Pub. 100-2, chapter 15, and section 40.9. Among other things, the affidavit must be in writing and signed by the eligible practitioner. It must include various statements to which the eligible practitioner must agree; for example, the eligible practitioner must agree not to submit claims to Medicare for any services furnished during the opt-out period except for emergency or urgent care services furnished to beneficiaries with whom the eligible practitioner has not previously entered into a private contract. It must identify the eligible practitioner sufficiently so that the MAC can ensure that no payment is made to the eligible practitioner during the opt-out period, and it must be filed with all MACs who have jurisdiction over the claims the eligible practitioner would have otherwise filed with Medicare and must be filed no later than 10 days after entering into the first private contract to which the affidavit applies.

Emergency and urgent care services

In the case that an eligible practitioner who has opted-out of Medicare provides emergency or urgent care services, that eligible practitioner must submit an application for enrollment via the Provider Enrollment Chain and Ownership System (PECOS) or a paper CMS-855I application. Once the eligible practitioner has received his/her Provider Transaction Access Number (PTAN), he/she must submit the claim(s) for any emergency or urgent care service provided.
Please refer to Pub. 100-02, Chapter 15, Section 40.28 for more information on emergency and urgent care services.

Eligible physician/non-physician practitioners

Eligible Physicians
Doctors of medicine (MD)
Doctors of osteopathy (DO)
Doctors of dental surgery (DDS)
Doctors of dental medicine (DMD)
Doctors of podiatry (DPM)
Doctors of optometry (OD)
Eligible Non-Physician Practitioners
Physician assistants (PA)
Nurse practitioners (NP)
Clinical nurse specialists (CNS)
Certified registered nurse anesthetists (CRNA)
Certified nurse midwives (CNM)
Clinical psychologists (PsyD, EdD, PhD)
Licensed clinical social workers (LCSW)
Registered dieticians/nutrition professionals (RD, MNT)

Eligible physician/non-physician practitioners who may order and refer

Doctors of medicine (MD)
Doctors of osteopathy (DO)
Doctors of dental surgery (DDS)
Doctors of dental medicine (DMD)
Doctors of podiatry (DPM)
Doctors of optometry (OD)
Physician assistants (PA)
Nurse practitioners (NP)
Clinical nurse specialists (CNS)
Certified registered nurse anesthetists (CRNA)
Certified nurse midwives (CNM)
Clinical psychologists (PsyD, EdD, PhD)
Licensed clinical social workers (LCSW)

Private contract requirements

In order to opt-out of Medicare, the eligible practitioner shall complete a “private contract” with their patients who are Medicare beneficiaries. A private contract pdf file must:
Be in writing and in print sufficiently large enough to ensure that the beneficiary is able to read the contract;
Clearly state whether the physician/practitioner is excluded from Medicare under 1128, 1156 or 1892 of the Act;
State that the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner;
State that the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner;
State that the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare;
State that the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted;
State that the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out;
State the expected or known effective date and the expected or known expiration date of the current two-year opt-out period;
State that the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare;
Be signed by the beneficiary or the beneficiary’s legal representative and by the physician/practitioner;
Not be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 40.28);
Be provided (a photocopy is permissible) to the beneficiary or to the beneficiary’s legal representative before items or services are furnished to the beneficiary under the terms of the contract;
Be retained (original signatures of both parties required) by the physician/practitioner for the duration of the current 2-year opt-out period;
Be made available to CMS upon request; and
Be entered into for each two-year opt-out period.

Opt-out affidavit requirements

As stated in Pub. 100-02, Chapter 15, Section 40.9, the affidavit shall state the following, that upon signing the affidavit, the eligible practitioner agrees to the following requirements:
1. Except for emergency or urgent care services, during the opt out period the eligible practitioner will provide services to Medicare beneficiaries only through private contracts, but for their provision under a private contract, would have been Medicare-covered services;
2. The eligible practitioner will not submit a claim to Medicare for any service furnished to a Medicare beneficiary during the opt out period, nor will the eligible practitioner permit any entity acting on the eligible practitioner’s behalf to submit a claim to Medicare for services furnished to a Medicare beneficiary;
3. During the opt out period, the eligible practitioner understands that he/she may receive no direct or indirect Medicare payment for services that the eligible practitioner furnishes to Medicare beneficiaries with whom the eligible practitioner has privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary under a Medicare Advantage plan;
4. An eligible practitioner who opts out of Medicare acknowledges that, during the opt out period, the eligible practitioner’s services are not covered under Medicare and that no Medicare payment may be made to any entity for the eligible practitioner’s services, directly or on a capitated basis;
5. On acknowledgment by the eligible practitioner to the effect that, during the opt out period, the eligible practitioner agrees to be bound by the terms of both the affidavit and the private contracts that the eligible practitioner has entered into;
6. Acknowledge that the eligible practitioner recognizes that the terms of the affidavit apply to all Medicare-covered items and services furnished to Medicare beneficiaries by the eligible practitioner during the opt out period (except for emergency or urgent care services furnished to the beneficiaries with whom the eligible practitioner has not previously privately contracted) without regard to any payment arrangements the eligible practitioner may make;
7. With respect to an eligible practitioner who has signed a Part B participation agreement, acknowledge that such agreement terminates on the effective date of the affidavit;
8. Acknowledge that the eligible practitioner understands that a beneficiary who has not entered into a private contract and who requires emergency or urgent care services may not be asked to enter into a private contract with respect to receiving such services;
9. Identify the eligible practitioner sufficiently so that the Medicare contractor can ensure that no payment is made to the eligible practitioner during the opt-out period; and
10. Be filed with all MACs who have jurisdiction over claims the eligible practitioner would otherwise file with Medicare, and 42 CFR 405.420 the initial 2-year opt-out period will begin the date the affidavit meeting the requirements of is signed, provided the affidavit is filed within 10 days after the eligible practitioner signs his or her first private contract with a Medicare beneficiary.
Please use this affidavit sample pdf file and mail to:
First Coast Service Options
Provider Enrollment Services
P.O. Box 3409
Mechanicsburg, PA 17055-1849

Renewal of the opt-out status

Valid opt-out affidavits signed on or after June 16, 2015, will automatically renew every two years. If physicians and practitioners who filed affidavits effective on or after June 16, 2015, do not want their opt-out to automatically renew at the end of a two-year opt-out period, they may cancel the renewal by notifying all contractors with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.
Valid opt-out affidavits signed before June 16, 2015, will expire two years after the effective date of the opt-out. If physicians and practitioners who filed affidavits effective before June 16, 2015, want to extend their opt-out, they must submit a renewal affidavit within 30 days after the current opt-out period expires to all contractors with which they would have filed claims absent the opt-out.

Cancellation of the opt-out status

If the eligible practitioner decides to enroll in Medicare after his or her opt-out is canceled, he or she must submit an application via PECOS or a paper CMS-855I application at least 30 days prior to the start of the next two-year opt-out period. The effective date of enrollment cannot be before the cancellation date of the opt-out period.
For example, an eligible practitioner submits a cancellation of his or her opt-out to end the period on March 31, which is two years from the eligible practitioner’s opt-out affidavit effective date. His/her requested Medicare effective date of enrollment cannot be before April 1.

Early termination of the opt-out status

If a physician or practitioner changes his/her mind once the affidavit has been approved by the carrier, the opt out may be terminated within 90 days of the effective date of the affidavit. To properly terminate an opt-out affidavit, a physician or practitioner must:
Not have previously opted out of Medicare
Notify all Medicare carriers, with which he/she filed an affidavit, of the termination of the opt out no later than 90 days after the effective date of the opt out period
Refund to each beneficiary with whom he/she has privately contracted all payment collected in excess of
The Medicare limiting charge (in the case of physicians or practitioners)
The deductible and coinsurance (in the case of practitioners).
Notify all beneficiaries with whom the physician or practitioner entered into private contracts of the physician’s or practitioner's decision to terminate opt out and of the beneficiaries’ right to have claims filed on their behalf with Medicare for services furnished during the period between the effective date of the opt out and the effective date of the termination of the opt out period. In the event such claims are filed and have already been paid by the beneficiaries, the paid amount must be indicated on the claim.
When the physician or practitioner properly terminates the opt-out in accordance with the second bullet above, he/she will be reinstated in Medicare as if they had not opted out.

Opt-out provider listing

The following link to the CMS website provides a listing of eligible practitioners that are currently opted-out of Medicare: https://data.cms.gov/Medicare-Enrollment/Opt-Out-Affidavits/7yuw-754z. external link
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.