What does it mean to opt out of Medicare?
You don’t want to bill Medicare for your services, but instead want your Medicare patients to pay out of pocket. Medicare coverage would apply when you order or certify items and services.
Please note, your decision to opt out will be made public on the CMS Opt-Out Dataset.
Impacts on Medicare Advantage (MA) plans:
- May not pay (directly or indirectly) on any basis, for basic benefits furnished to a Medicare enrollee by a physician or other practitioner (as noted below) who has filed a valid opt-out affidavit with Medicare, and
- Must pay for urgent care or emergency services furnished by a physician or practitioner who has not signed a private contract with the beneficiary they are treating.
- May make payment to an opted-out physician or practitioner for services that are not basic benefits, but are provided to a beneficiary as a supplemental benefit consistent with regulations found at 42 CFR §422.102.
To opt out, you will need to:
- Be of an eligible type or specialty.
- Submit an opt-out affidavit to Medicare.
- Enter into a private contract with each of your Medicare patients. This contract will reflect the agreement between you and your patients that they will pay out of pocket for services, and that nobody will submit the bill to Medicare for reimbursement.
Contact your Medicare Administrative Contractor (MAC) (PDF) to see what information you should include in your opt-out affidavit and private contract.
Canceling an Opt-Out Status
To cancel your opt-out status, you’ll need to mail a cancellation request to your MAC at least 30 days before your opt-out period is set to expire. If you don’t submit your cancellation request before the 30-day period, your opt-out status will automatically renew for another two-year cycle.
You can terminate your opt-out status within the first 90 days of submitting an initial opt-out affidavit. (Once an opt-out has been automatically renewed, you can no longer terminate early.)
Renewing an Opt-Out Status
If you’re currently opted out, your opt-out status will automatically renew every two years.i If you submitted an opt-out affidavit before June 16, 2015 and never renewed it, you’ll need to submit a new opt-out affidavit.
Providers Eligible to Opt Out
- Doctors of medicine
- Doctors of osteopathy
- Doctors of dental surgery or dental medicine
- Doctors of podiatric medicine
- Doctors of optometry
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Certified nurse midwives
- Clinical psychologists
- Clinical social workers
- Registered dieticians and nutrition professionals
Providers NOT Eligible to Opt Out
- Anesthesiology assistants
- Occupational therapists
- Physical therapists
- Qualified audiologists
- Qualified speech language pathologists
i If you submitted your last opt-out affidavit prior to June 16, 2015, your opt out status would not have renewed automatically.