What it means when a provider opts out of Medicare
Certain doctors and other health care providers who don’t want to work with the Medicare program may “opt out” of Medicare. Medicare doesn’t pay for any covered items or services you get from an opt out doctor or other provider, except in the case of an emergency or urgent need. If you still want to see an opt out provider, you and your provider can set up payment terms that you both agree to through a private contract.
A doctor or other provider who chooses to opt out must do so for 2 years, which automatically renews every 2 years unless the provider requests not to renew their opt out status.
Getting care from providers who’ve opted out of Medicare
When you get care from a provider who’s opted out of Medicare: neither you nor the provider will submit a bill to Medicare for the services you get from that provider and Medicare won’t reimburse you or the provider. Instead, the provider bills you directly and you pay the provider out-of-pocket. The provider isn’t required to accept only Medicare’s fee-for-service charges. You can still get care from these providers, but they must enter into a private contract with you (unless you’re in need of emergency or urgently needed care). If you’re unsure if a provider has opted out of Medicare, you may want to check so you’ll know ahead of time if you’ll need to pay out-of-pocket for your care.
What to know about private contracts
A private contract is a written agreement between you and a doctor or other health care provider who has decided not to provide services to anyone through Medicare. The private contract only applies to the services provided by the doctor or other provider who asked you to sign it.
Rules for private contracts
- You don’t have to sign a private contract. It is only required if you want to continue with your “opted out” provider.
- You can always go to another provider who gives services through Medicare.
- If you sign a private contract with your doctor or other provider, these rules apply:
- You’ll have to pay the full amount of whatever this provider charges you for the services you get.
- You and your provider will set up your own payment terms through the contract.
- If you have a Medicare Supplement Insurance (Medigap) policy, it won’t pay anything for the services you get.
- Call your insurance company before you get the service if you have questions.
- You’re always free to get services Medicare doesn’t cover if you choose to pay for a service yourself.
- You may want to contact your State Health Insurance Assistance Program (SHIP) to get help before signing a private contract with any doctor or other health care provider
**Information from Medicare.gov website