Page 30 - Medicare Benefit Policy Manual

• Be in writing and in print sufficiently large to ensure that the beneficiary is able
to read the contract;

• Clearly state whether the physician/practitioner is excluded from Medicare under
§§1128, 1156 or 1892 of the Act;

• State that the beneficiary or the beneficiary’s legal representative accepts full
responsibility for payment of the physician’s or practitioner’s charge for all
services furnished by the physician/practitioner;

• State that the beneficiary or the beneficiary’s legal representative understands
that Medicare limits do not apply to what the physician/practitioner may charge
for items or services furnished by the physician/practitioner;

• State that the beneficiary or the beneficiary’s legal representative agrees not to
submit a claim to Medicare or to ask the physician/practitioner to submit a claim
to Medicare;

• State that the beneficiary or the beneficiary’s legal representative understands
that Medicare payment will not be made for any items or services furnished by
the physician/practitioner that would have otherwise been covered by Medicare if
there was no private contract and a proper Medicare claim had been submitted;

• State that the beneficiary or the beneficiary’s legal representative enters into the
contract with the knowledge that the beneficiary has the right to obtain Medicare-
covered items and services from physicians and practitioners who have not opted
out of Medicare, and that the beneficiary is not compelled to enter into private
contracts that apply to other Medicare-covered services furnished by other
physicians or practitioners who have not opted out;

• State the expected or known effective date and the expected or known expiration
date of the current 2-year opt-out period;

• State that the beneficiary or the beneficiary’s legal representative understands
that Medigap plans do not, and that other supplemental plans may elect not to,
make payments for items and services not paid for by Medicare;

• Be signed by the beneficiary or the beneficiary’s legal representative and by the
physician/practitioner;

• Not be entered into by the beneficiary or by the beneficiary’s legal representative
during a time when the beneficiary requires emergency care services or urgent
care services. (However, a physician/practitioner may furnish emergency or
urgent care services to a Medicare beneficiary in accordance with §40.28);