When a Physician or Practitioner Opts Out of Medicare

40.5 - When a Physician or Practitioner Opts Out of Medicare (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16) When a physician/practitioner opts-out of Medicare, Medicare covers no services provided by that individual and no Medicare payment can be made to that physician or practitioner directly or on a capitated basis. Additionally, no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. EXCEPTION: In an emergency or urgent care situation, a physician/practitioner who opts-out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the physician/practitioner may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary’s behalf. Payment will be made for Medicare covered items or services furnished in emergency or urgent situations when the beneficiary has not signed a private contract with that physician/practitioner. (See §40.28.) Under the statute, the physician/practitioner cannot choose to opt-out of Medicare for some Medicare beneficiaries but not others; or for some services but not others. The physician/practitioner who chooses to opt-out of Medicare may provide covered care to Medicare beneficiaries only through private contracts. Medicare will make payment for covered, medically necessary services that are ordered or certified by a physician/practitioner who has opted out of Medicare if the ordering or certifying physician/practitioner has acquired a National Provider Identifier (NPI), reports his/her Social Security Number, has a valid opt-out affidavit on file with his or her Medicare Administrative Contractor (MAC), is of a specialty that is eligible to order and certify, and provided that the services are not furnished by another physician/practitioner who has also opted out. For example, if an opt-out physician/practitioner admits a beneficiary to a hospital, Medicare will reimburse the hospital for medically necessary care.