Page 27 - Medicare Benefit Policy Manual

For purposes of this provision, the term “physician” is limited to doctors of medicine;
doctors of osteopathy; doctors of dental surgery or of dental medicine; doctors of
podiatric medicine; and doctors of optometry who are legally authorized to practice
dentistry, podiatry, optometry, medicine, or surgery by the State in which such function
or action is performed; no other physicians may opt out. Also, 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;
• Clinical social worker;
• Registered dietitian; or

• Nutrition Professional

The opt out law does not define “physician” to include chiropractors; therefore, they may
not opt out of Medicare and provide services under private contract. Physical therapists in
independent practice and occupational therapists in independent practice cannot opt out
because they are not within the opt out law’s definition of either a “physician” or
“practitioner”.

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.)