Opt Out of Medicare

Opt out is a contract between a provider, beneficiary and Medicare where the provider or beneficiary does not file a claim to Medicare. The physician or practitioner bills the beneficiary directly and is not required to follow the fee-for-service charges determined by Medicare.

In order to opt-out, providers must submit an Opt Out Affidavit with Medicare and must keep a Private Contract with all beneficiaries on file for each two-year period. Follow the below links to learn more about opting out.

Opt Out Overview

There are, basically, three reasons why an individual provider may "opt out" of Medicare.

  1. To become eligible to order, certify and prescribe
  2. They prescribe Part D Prescriptions to Medicare Patient
  3. They do not wish to enroll in the Medicare program

To prescribe drugs covered by a Medicare Advantage plan, providers must enroll in Medicare. Providers eligible to prescribe Part D drugs and order/certify may submit the CMS 855O.

Providers who do not wish to enroll in the Medicare program, may opt-out. To "opt out" means a beneficiary pays a physician out-of-pocket and no one is reimbursed by Medicare. See table below for provider types who may or may not opt out. If a provider is able to opt out, they must:

  • Submit an Opt-Out Affidavit expressing his/her decision to opt-out
  • Sign private Medicare Opt-Out Private Contracts
  • Be legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the state in which such function or action is performed
  • Be legally authorized to practice by the state and otherwise meet Medicare requirements
  • Once a provider opts out of Medicare, they are opted out across the United States of America and territories. If the provider goes from one MAC to another, an additional opt out affidavit is required to be submitted to the new MAC
    • Example: Provider sees patient in South Dakota and then sees a patient in Iowa. The provider is required to submit an opt out affidavit to the MAC that oversees Iowa.
Providers Eligible to Opt Out Providers NOT 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
  • Groups/Organizations
  • Part A enrollments
  • Chiropractor
  • Anesthesiologist assistant
  • Speech Language Pathologist
  • Physical Therapists
  • Occupational Therapists
  • Any specialty not eligible to enroll in Medicare

 

Providers who opt out must be aware of the below.

  • An Affidavit must be filed with all carriers who have jurisdiction over claims the physician/practitioner would otherwise file with Medicare.
  • The opt out period lasts two years.
  • Opt outs will auto-renew at the end of the two-year period without a need to resubmit an updated affidavit.
  • If a provider wishes to cancel the automatic renewal extension, they must notify the MAC in writing at least 30 days prior to the start of the next two-year opt-out period.
  • All active Medicare enrollments will be terminated.
  • Opting out means you cannot be involved in any Medicare program; including original fee-for-service Medicare, Medicare Managed Care Plans, Medicare+Choice Plan and Medicare Advantage Plan.
  • Providers cannot be opted-out for some services and not others, as well as some locations and not others.
  • No payment through Medicare

When to Send in the Opt Out

  • If the provider has been previously enrolled in Medicare and were set-up as a PAR provider, the provider must submit a valid affidavit, post marked 30 days prior to the first day of each new quarter (January, April, July, or October)
    • Example #1: If we received the affidavit on November 15, 2019; then the opt out effective date would be January 1, 2020
    • Example #2: If we received the affidavit on December 5, 2019; then the opt out effective date would be April 1, 2020
  • If the provider has been previously enrolled in Medicare and were set-up as a Non-PAR provider, then the affidavit can be submitted any time.
    • The effective date would be the day the affidavit was signed
  • If the provider has never been enrolled with Medicare, then the affidavit can be submitted any time.
    • The effective date would be the day the affidavit was signed

Processing Time-frame and Changes

  • Opt out applications will be processed within 60 days
  • If we need additional information, we will send one development request.
  • The provider will have 30 days to submit the information.
    • We will reject the opt out if we do not get the information requested.
  • If the address of the opted-out provider needs to be updated, a new affidavit with the new address and a coversheet stating the provider is updating their address is required to be mailed in

Appeals

Opt outs can be reconsidered (Appealed). This request must be sent to CMS. If the opt out is sent to Noridian, we will return the opt out advising it will need to be sent to CMS. This must follow the guidelines below:

  • Be requested in writing within 60 calendar days of the postmark date of the notification letter (or within 60 calendar days after the 90-day period to terminate ends) and mailed to the address listed therein.
  • State the issues or findings of fact with which you disagree and the reasons for disagreement.
  • Be signed by the eligible practitioner or an authorized legal representative.
    • If the authorized legal representative is an attorney, the attorney's statement that he or she has the authority to represent the provider or supplier is sufficient to accept this individual as the legal representative.
  • If the authorized legal representative is not an attorney, the eligible practitioner must file written notice of the appointment of its representative with the submission of reconsideration request.

Emergency Services

  • If a provider has elected to Opt Out of Medicare, they cannot bill for any current patients or clients for any reason except for emergency situations
  • Example of emergencies:
    • Provider assists in a car accident for an unknown victim
    • Provider assists in providing services after a natural disaster
  • In order to bill for these services, the provider will need to fully enroll.
    • Submit an application for enrollment via the Provider Enrollment Chain and Ownership System (PECOS) or a paper CMS-855I application.
    • Once the Provider Transaction Access Number (PTAN) has been received, claims must be submitted for any emergency or urgent care service(s) provided.
    • Keep in mind the timeliness requirements, which typically require submission of the 855I no later than 30 days after the service occurred, in order for the Noridian to honor the effective date.
    • Noridian will work with CMS for guidance when this type of situation arises and work with the eligible practitioner to get their PTAN set up.
  • Refer to Pub. 100-02, Chapter 15, Section 40.28 for more information on Emergency and Urgent Care Services.

Renewal of Opt Out Status

  • Current opt out providers are automatically renewed every two (2) years. If an affidavit has not been signed and received by the Medicare contract on/after June 16, 2015, a new affidavit must be submitted to start a new opt out period.
  • Notification letters will be sent roughly 90 days before the opt out is due to renew. The letter advises that the opt out will be renewed shortly.
  • If the provider wishes to terminate your auto-renewal, he/she must submit the cancellation request via a letter 30 days before the opt out is due to expire.

Cancellation of Opt Out Status

If a provider wishes to end his/her opt out status and reenroll in Medicare, he/she must submit the cancellation request via a letter 30 days before the opt out is due to expire. If the cancellation letter is submitted after the 30 days, he/she will remain opted out for another 2-year cycle. This must be mailed in.

Early Termination

  • A providers opt out status may be voluntarily terminated within 90 days of the affidavit if a provider has not previously been in an opt out status.
  • This only applies to initial opt out providers. This does not apply to providers who renew their opt out status
  • All previous enrollments with Medicare will be reactivated at the time of the termination of the opt out period.

Ordering, Certifying and Prescribing Status

  • A provider who has opted out of Medicare is eligible to order, certify and prescribe by supplying the required Social Security Number, Date of Birth and NPI on the Opt Out Affidavit. If both elements are not supplied the provider will not be approved to order, certify and/or prescribe.
  • If the provider wishes to order and refer services, this must be indicated on the affidavit. The provider will need to check mark the box Yes or No on the affidavit template or includes this statement if creating their own affidavit form.
    • If no is selected, the provider will not be set up to order and refer services
  • To learn more about opting out and ordering, certifying and prescribing Part D drugs, see CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 15

Affidavit

  • To use the suggested Affidavit on our website, use this link Affidavit.
  • If the provider wishes to order and refer services, ensure the provider check mark the box Yes or No on the affidavit.
  • A provider may also create their own affidavit. All affidavits must have the information below.
Required Affidavit Statements
  • Be in writing and be signed and dated by physician/practitioner
  • Contain physician's or practitioner's full legal name, address, telephone number, specialty, National Provider Identifier (NPI), if assigned, License Information and Social Security Number (required if provider does not have an NPI and/or wishes to order, certify and/or Prescribe Part D drugs)
  • State that except for emergency or urgent care services the physician/practitioner will provide services to Medicare beneficiaries during opt out period only through private contracts that meet criteria for private contracts, for services that would have been Medicare-covered services but for their provision under a private contract
  • State that physician/practitioner will not submit a claim to Medicare for any service furnished to a Medicare beneficiary during opt out period, nor will physician/practitioner permit any entity acting on his/her behalf to submit a claim to Medicare for services furnished to a Medicare beneficiary, except for emergency and urgent care services provided to a Medicare beneficiary with whom he/she has not signed a private contract
  • State that, during opt out period, physician/practitioner understands that he/she may receive no direct or indirect Medicare payment for services that he/she furnishes to Medicare beneficiaries with whom he/she 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+Choice plan
  • State that physician/practitioner who opts out of Medicare acknowledges that, during opt out period, his/her services are not covered under Medicare and that no Medicare payment may be made to any entity for his/her services, directly or on a capitated basis
  • State a promise by physician/practitioner to the effect that, during opt out period, physician/practitioner agrees to be bound by terms of both affidavit and private contracts that he/she has entered into
  • Acknowledge that physician/practitioner recognizes that terms of affidavit apply to all Medicare-covered items and services furnished to Medicare beneficiaries by physician/practitioner during opt out period (except for emergency or urgent care services furnished to beneficiaries with whom he/she has not previously privately contracted) without regard to any payment arrangements physician/practitioner may make
  • With respect to physician/practitioner who has signed a Part B participation agreement, acknowledge that such agreement terminates on affidavit effective date
  • Acknowledge that physician/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 and that rules for emergency and urgent care apply if physician/practitioner furnishes such services
  • Identify physician/practitioner sufficiently so that the Medicare contractor can ensure that no payment is made to physician/practitioner during opt out period
  • Be filed with all carriers who have jurisdiction over claims physician/practitioner would otherwise file with Medicare and be filed no later than 10 days after first private contract to which affidavit applies is entered into

Complete the affidavit and send it to Noridian using the state specific mailing address provided on the Mailing Addresses webpage.

 

Private Contract

  • To use the suggested Private Contract on our website, use this link Private Contract.
  • A provider may also create their own private contract. All private contracts must have the information below.
  • A contract must be completed for each beneficiary and be kept on file for the two-year period.
Required Private Contract Statements

All private contracts must have the following information.

  • Be in writing and in print sufficiently large to ensure that beneficiary is able to read contract
  • Clearly state whether physician/practitioner is excluded from Medicare under Sections 1128, 1156, or 1892 of the Social Security Act
  • State that beneficiary or beneficiary's legal representative accepts full responsibility for payment of physician's or practitioner's charge for all services furnished by physician/practitioner
  • State that beneficiary or his/her legal representative understands that Medicare limits do not apply to what physician/practitioner may charge for items or services furnished by physician/practitioner
  • State that beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask physician/practitioner to submit a claim to Medicare
  • State that beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by 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 beneficiary or legal representative enters into contract with knowledge that he/she has 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 apply to Medicare-covered services furnished by other physicians or practitioners who have not opted out
  • State expected or known effective date and expected or known expiration date of opt out period. Effective with affidavits signed after June 16, 2015, opt out providers will automatically renew every two-year period
  • State that beneficiary or his/her 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 beneficiary or his/her legal representative and by physician/practitioner prior to any services provided under contract's terms
  • Not be entered into by beneficiary or by beneficiary's legal representative during a time when beneficiary requires emergency care services or urgent care services
  • Be provided (a photocopy is permissible) to beneficiary or to his/her legal representative before items or services are furnished to beneficiary under terms of contract
  • Be retained (original signatures of both parties required) by physician/practitioner for duration of opt out period
  • Be made available to CMS upon request
  • Be entered into for each opt out period

 

Last Updated Fri, 10 Jan 2020 13:49:33 +0000