Sample Affidavit For Opting Out Of Medicare (Page 3 of 6) in pdf

How often can a physician or practitioner "opt out" or return to Medicare?

Pursuant to the statute, once a physician or practitioner files an affidavit notifying the Medicare carrier that he or she has

opted out of Medicare, he or she is out of Medicare for two years from the date the affidavit is signed. After those two

years are over, a physician or practitioner could elect to return to Medicare or to "opt out" again.

Can a physician or practitioner "opt out" for some carrier jurisdictions but not others?

No. The "opt out" applies to all items or services the physician or practitioner furnishes to Medicare beneficiaries,

regardless of the location where such item or service is furnished.

What is the effective date of the "opt out" provision?

A physician or practitioner may enter into a private contract with a beneficiary for services furnished at any time after

January 1998. The physician or practitioner must submit the affidavit to all pertinent Medicare carriers within 10 days of

the date the first private contract is signed by a Medicare beneficiary.

Does the statute preclude physicians from treating Medicare beneficiaries if they treat private pay patients?

No. Medicare does not preclude physicians from treating Medicare beneficiaries if they treat private pay patients, whether

they are persons under age 65 or seniors who choose not to enroll in Part B.

Do Medicare rules apply for services not covered by Medicare?

If Medicare does not cover a service, Medicare rules, including "opt out" rules, do not apply to the furnishing of the non-

covered service. For example, Medicare does not cover hearing aids; therefore, there are no limits on charges for hearing

aids and beneficiaries pay completely out of their own pocket if they want hearing aids.

Is a private contract needed for services not covered by Medicare?

No. Since Medicare rules do not apply for services not covered by Medicare, a private contract is not needed. A private

contract is needed only for services that are covered by Medicare and where Medicare may make payment if a claim were

submitted.

A physician or practitioner may furnish a service that Medicare covers under some circumstances but which the physician

anticipates would not be deemed "reasonable and necessary" by Medicare in the particular case (e.g., multiple nursing

home visits, some concurrent care services, two mammograms within a twelve month period, etc.). If the beneficiary

receives an Advanced Beneficiary Notice that the service may not be covered by Medicare and that the beneficiary will

have to pay for the service if it is denied by Medicare, a private contract is not necessary to bill the beneficiary if the claim

is denied.

What rules apply to urgent or emergency treatment?

The law precludes a physician or practitioner from having a beneficiary sign a private contract when the beneficiary is

facing an urgent or emergency health care situation.

Where a physician or practitioner who has opted out of Medicare treats a beneficiary with whom he does not have a

private contract in an emergency or urgent situation, the physician or practitioner may not charge the beneficiary more

than the Medicare limiting charge for the service and must submit the claim to Medicare for the emergency or urgent care.

Medicare payment may be made to the beneficiary for the Medicare covered services furnished to the beneficiary.

Will Medicare make payment for services that are ordered by a physician or practitioner who has opted out of

Medicare?

Yes, provided that the "opt out" physician or practitioner ordering the service has acquired a Unique Provider Identification

Number (UPIN).

Clinical psychologists and clinical social workers are currently not recognized by and enrolled by Medicare

unless they meet certain criteria specified by HCFA, some of which are voluntary. Are the requirements for

opting out of Medicare different for these practitioners?

No. A clinical psychologist or clinical social worker must meet the affidavit and private contracting rules to "opt out" of

Medicare.

What is the relationship between an Advanced Beneficiary Notice and a private contract?

A physician or practitioner may furnish a service that Medicare covers under some circumstances but which the physician

anticipates would not be deemed reasonable and necessary under Medicare program standards in the particular case

(such cases are also referred to as medical necessity denials). If the beneficiary receives an Advanced Beneficiary Notice

that the service may not be covered by Medicare and that the beneficiary will have to pay for the service if it is denied by

Medicare, a private contract is not necessary to bill the beneficiary if the claim is denied.

Sample Affidavit For Opting Out Of Medicare Page 3

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