Page 32 - Medicare Benefit Policy Manual

affidavits with their MAC. Section 106(a) of the MACRA amends section 1802(b)(3) of
the Act to require that opt-out affidavits filed on or after June 16, 2015, automatically
renew every 2 years. Therefore, physicians and practitioners that filed opt-out affidavits
on or after June 16, 2015, are not required to file renewal affidavits to continue their opt-
out status. Furthermore, physicians and practitioners who filed opt-out affidavits on or
after June 16, 2015, and who do not want their opt-out status to automatically renew at
the end of a 2-year opt-out period may cancel the automatic extension by notifying their
MACs in writing at least 30 days prior to the start of the next 2-year opt-out period.
Valid opt-out affidavits signed before June 16, 2015, will expire 2 years after the
effective date of the opt-out. If physicians and practitioners that filed affidavits effective
before June 16, 2015, want to extend their opt-out, they must submit a renewal affidavit
within 30 days after the current opt-out period expires to all contractors with which they
would have filed claims absent the opt-out.

Under 1802(b)(3)(B) and (D) of the Act and Medicare regulations, a valid affidavit must:

• Be in writing and be signed by the physician/practitioner;

• Contain the physician’s or practitioner’s full name, address, telephone number,
NPI or billing number (if one has been assigned), or, if an NPI has not been
assigned, the physician’s or practitioner’s tax identification number (TIN);

• State that, except for emergency or urgent care services (as specified in §40.28),
during the opt-out period the physician/practitioner will provide services to
Medicare beneficiaries only through private contracts that meet the criteria of
§40.8 for services that, but for their provision under a private contract, would
have been Medicare-covered services;

• State that the physician/practitioner will not submit a claim to Medicare for any
service furnished to a Medicare beneficiary during the opt-out period, nor will the
physician/practitioner permit any entity acting on the physician’s/practitioner’s
behalf to submit a claim to Medicare for services furnished to a Medicare
beneficiary, except as specified in §40.28;

• State that, during the opt-out period, the physician/practitioner understands that
the physician/practitioner may receive no direct or indirect Medicare payment for
services that the physician/practitioner furnishes to Medicare beneficiaries with
whom the physician/practitioner has privately contracted, whether as an
individual, an employee of an organization, a partner in a partnership, under a
reassignment of benefits, or as payment for a service furnished to a Medicare
beneficiary under a Medicare Advantage plan;

• State that a physician/practitioner who opts-out of Medicare acknowledges that,
during the opt-out period, the physician’s/practitioner’s services are not covered
under Medicare and that no Medicare payment may be made to any entity for the
physician’s/practitioner’s services, directly or on a capitated basis;