Sample Affidavit For Opting Out Of Medicare printable pdf download

GUIDELINES FOR "OPTING OUT" OF MEDICARE

Effective January 1, 1998, a physician or practitioner may enter into a private contract with a beneficiary for furnished

services for Medicare. As provided in section 4507 of the Balanced Budget Act of 1997, a private contract is a contract

between a Medicare beneficiary and a physician or other practitioner who has opted out of Medicare for two years for all

covered items and services he/she furnishes to Medicare beneficiaries. In a private contract, the Medicare beneficiary

agrees to give up Medicare payment for services furnished by the physician or practitioner and to pay the physician or

practitioner without regard to any limits that would otherwise apply to what the physician or practitioner could charge.

If you are a physician or practitioner who wishes to "opt out" of Medicare, then you must first terminate your Medicare Part

B participation agreement, then notify your Medicare patients of your intent to "opt out" of Medicare. Then you must file a

copy of an affidavit with each carrier that has jurisdiction over the claim that a physician or practitioner would otherwise file

with Medicare. (A sample affidavit is provided at the end of this document.) You must then enter into a private contract for

rendering any covered services to a Medicare beneficiary, and this contract must be written and signed prior to rendering

any covered service to a beneficiary. (A sample contract is provided at the end of this document.) Then you must

establish procedures in your office to ensure that your staff never files a Medicare claim, and never provides information

to a patient that will enable him to file a Medicare claim. The exception to this would be for emergency or urgent care, or

for a covered service that Medicare would deem unnecessary. This exception should be handled with extreme caution.

Below are a number of questions and answers pertaining to opting out of the Medicare program.

What has to be in a private contract and when must it be signed?

The private contract must be signed by both the beneficiary and the physician or practitioner before services can be

furnished under its terms. It must state plainly and unambiguously that by signing the private contract, the beneficiary or

the beneficiary's legal representative agree to the following terms:

1. Gives up all Medicare coverage of, and payment for, services furnished by the "opt out" physician or practitioner.

2. Agrees not to bill Medicare or ask the physician or practitioner to bill Medicare.

3. Is liable for all charges of the physician or practitioner, without any limits that would otherwise be imposed by

Medicare.

4. Acknowledges that Medigap will not pay towards the services and that other supplemental insurers may not pay

either.

5. Acknowledges that he/she has the right to receive services from physicians and practitioners for whom Medicare

coverage and payment would be available.

The contract must also indicate whether the physician or practitioner has been excluded from Medicare.

A contract is not valid if it is entered into by a beneficiary or by a beneficiary's legal representative when the Medicare

beneficiary is facing an emergency or urgent health situation.

Who can "opt out" of Medicare under this provision?

Physicians and practitioners can "opt out" of Medicare. For purposes of this provision, the term "physician" is limited to

doctors of medicine and doctors of osteopathy who are legally authorized to practice medicine and surgery by the state in

which such function or action is performed. No other physicians may "opt out". For purposes of this provision, the term

"practitioner" means any of the following to the extent that they are legally authorized to practice by the state and

otherwise meet Medicare requirements: physician assistant, nurse practitioner, clinical nurse specialist, certified

registered nurse anesthetist, certified nurse midwife, clinical psychologist, or clinical social worker.

The "opt out" law does not define "physician" to include optometrists, chiropractors, podiatrists, dentists, and doctors of

oral surgery. Therefore, they may not "opt out". Physical therapists and occupational therapists in independent practice

cannot "opt out".

Can physicians or practitioners who are suppliers of durable medical equipment (DME), independent diagnostic

testing facilities, clinical laboratories, etc., "opt out" of Medicare for only these services?

No. If a physician or practitioner chooses to "opt out" of Medicare, it means that he or she opts out for all covered items

and services he/she furnishes, even if those items or services are covered under a different benefit. Physicians and

practitioners cannot have private contracts that apply to some covered services they furnish, but not to others. If a

physician or practitioner provides laboratory tests or durable medical equipment and chooses to "opt out" of Medicare,

then he/she has opted out of Medicare for payment of lab services and DME as well as for professional services. If a

physician who has opted out refers a beneficiary for medically necessary services, such as laboratory, DME or inpatient

hospitalization, those services would be covered.

How can participating physicians and practitioners "opt out" of Medicare?

Participating physicians and practitioners may "opt out" if they file an affidavit that meets the criteria and which is received

by the carrier at least 30 days before the first day of the next calendar quarter showing an effective date of the first day in

Sample Affidavit For Opting Out Of Medicare

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