Opt Out Information - Part B
Overview
A physician or practitioner may "opt out" of Medicare and enter into private contracts with Medicare beneficiaries if specific requirements 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 (see the guidelines in each section below).
Opt Out Affidavits Guidelines and Addresses 
Provider Specialties: Who can opt out of Medicare
Early Termination of Opt Out
A physician/practitioner may terminate the opt out agreement within 90 days of the affidavit's effective date. To properly terminate, an opt out physician or practitioner must:
- Not have previously opted out of Medicare.
- Notify all Medicare carriers, with which an affidavit was filed, of the termination no later than 90 days after the effective date of the opt out period.
- Refund to each beneficiary, with whom there is a private contract, all payment collected in excess of the:
- Medicare limiting charge (in the case of physicians/practitioners) or
- Deductible and coinsurance (in the case of practitioners).
- Notify all beneficiaries with whom there is a private contract of:
- the decision to terminate opt out, and
- the beneficiaries' right to have claims filed with Medicare for services furnished between the effective dates of the opt out and the termination.
Effect of Reassignment When a Provider Opts Out of Medicare
When a physician or non-physician practitioner opts out of the Medicare program and is a member of a group practice or otherwise reassigns his or her right to bill and receive Medicare payment to an organization, the organization may no longer bill Medicare or receive Medicare payment for the services that the physician or non-physician practitioner furnishes to Medicare beneficiaries. However, if the physician or non-physician practitioner continues to grant the organization the right to bill and receive payment for the services he or she furnishes to patients, the organization may bill and be paid by the beneficiary for the services that are provided under the private contract. In addition, the decision of a physician or non-physician practitioner to opt out of Medicare does not affect the ability of the group practice or organization to bill Medicare for the services of physicians and/or non-physician practitioners who have not opted out of Medicare.
Emergency/Urgent Care Situations
In an emergency or urgent care situation, a provider may treat a Medicare beneficiary with whom he or she does not have a private contract and bill for such treatment. The provider may not charge the beneficiary more than the limiting charge and must submit a claim to Medicare on the beneficiary's behalf. Medicare payment may be made to the beneficiary for covered services in this situation.
To bill emergency/urgent services, use the GJ modifier. This indicates that the services were emergency or urgent and that there is no private contract.
Mandatory Claims Submission
Provisions regarding mandatory claims submission do not apply once a provider signs and submits an "opt out" affidavit to the carrier for the duration of the opt out period, unless the provider knowingly and willfully violates a term of the affidavit.
Opt Out Lists
Page Last Updated: Friday, 14-Nov-2008 16:28:16 CST
