“Opting Out” Of Medicare

Physicians who opt out of Medicare—meaning Medicare cannot be billed for any services they provide for a two-year opt-out period—can see Medicare patients under private contracts. These contracts allow physicians to establish their own fees; they are not limited by the Medicare fee schedule.

A physician who opts out of Medicare may not see any Medicare patients for two years. Medicare patients can, however, choose to see some physicians under Medicare and others under private contracts.

Physicians must send an opt-out affidavit to their local Medicare carrier before entering into private contracts with patients. Nonparticipating providers can opt out at any time, while participating providers must send the affidavit to the carrier 30 days before the beginning of the following quarter when their opt-out period will begin (the quarters begin on 1/1, 4/1, 7/1, and 10/1).

The private contract must say that the patient agrees in writing that he or she will not submit any claims to Medicare and will not ask the physician to submit any claims. The patient also acknowledges that Medigap plans (and possibly other supplemental plans) will not make payments for services rendered by the contracting physician, agrees to be fully responsible for payment to the contracting physician for services rendered, and acknowledges that Medicare’s fee schedule amounts and charge limits do not apply to the contracting physician. The private contract available on the APA Web site fulfills all the requirements.