What You Need to Know about Opt-Out/Private Contract Providers
Opt-Out Lists
A physician or practitioner may "opt out" of Medicare and enter into private contracts with Medicare beneficiaries if specific rules are met. When a provider "opts out" of Medicare, no services provided by that individual are covered by Medicare and no payment can be made to the physician or to beneficiaries except for services provided in an emergency/urgent care situation.
A private contract is a contract between a Medicare beneficiary and a provider who has opted out of Medicare for two years for all covered items and services furnished to Medicare beneficiaries. The beneficiary agrees to give up Medicare payment for services furnished by the provider and to pay the provider without regard to any limits that would otherwise apply to what the provider would charge.
Specialties That Can Opt Out Of Medicare
- Doctors of medicine and osteopathy
- Physician assistants (specialty 97)
- Nurse practitioners (specialty 50)
- Clinical nurse specialists (specialty 89)
- Certified registered nurse anesthetists (CRNAs) (specialty 43)
- Certified nurse midwives (specialty 42)
- Clinical social workers (specialty 80)
- Clinical psychologists (specialty 68)
- Dentists and Doctors of oral surgery (specialty 19)
- Podiatrists (specialty 48)
- Optometrists (specialty 41)
Specialties That May Not Opt Out
- Chiropractors (specialty 35)
- Physical therapists in independent practice (specialty 65)
- Occupational therapists (specialty 67)
The following is from the August 1998 CMS Medicare & You Fact Sheet: "Private Contracts With Doctors and Other Practitioners Who Have Decided Not To Provide Services Through The Medicare Program."
A Private Contract is a contract between a Medicare beneficiary and a doctor or other practitioner who has decided not to provide services through the Medicare program (not bill for any service or supplies to any Medicare beneficiary for at least 2 years). For more information, visit:
www.medicare.gov or call your State Health Insurance Assistance Program.
Under a Private Contract:
- No Medicare payment will be made for the services you receive.
- You will have to pay whatever the doctor or practitioner charges you with no limit on the charges for Medicare approved services (the limiting charge will not apply).
- Medicare Managed Care Plans will not pay for these services.
- No claim should be submitted, and Medicare will not pay if one is.
- If you have a Supplemental Insurance (Medigap) Policy, it will not pay anything for this service.
- Many other insurance plans also will not pay for the service.
The Private Contract only applies to the services provided by the doctor who asked you to sign it. You cannot be asked to sign a Private Contract when you are facing an emergency or urgent health situation. If you want to pay on your own for services the Original Medicare Plan doesn't cover, your doctor does not have to leave Medicare or ask you to sign a Private Contract. You are always free to obtain non-covered services on your own if you choose to pay for the service yourself. It may be helpful to talk with someone in your State Health Insurance Assistance Program before signing a Private Contract with any doctor or practitioner. To find assistance near you please check out our Medicare Information page by clicking here or select Medicare Info on the left hand side of this page.
Page Last Updated: Thursday, 17-Jul-2008 10:11:18 CDT
