Page 33 - Medicare Benefit Policy Manual

• State on acknowledgment by the physician/practitioner to the effect that, during
the opt-out period, the physician/practitioner agrees to be bound by the terms of
both the affidavit and the private contracts that the physician/practitioner has
entered into;

• Acknowledge that the physician/practitioner recognizes that the terms of the
affidavit apply to all Medicare-covered items and services furnished to Medicare
beneficiaries by the physician/practitioner during the opt-out period (except for
emergency or urgent care services furnished to the beneficiaries with whom the
physician/practitioner has not previously privately contracted) without regard to
any payment arrangements the physician/practitioner may make;

• With respect to a physician/practitioner who has signed a Part B participation
agreement, acknowledge that such agreement terminates on the effective date of
the affidavit;

• Acknowledge that the physician/practitioner understands that a beneficiary who
has not entered into a private contract and who requires emergency or urgent care
services may not be asked to enter into a private contract with respect to receiving
such services and that the rules of §40.28 apply if the physician/practitioner
furnishes such services;

• Identify the physician/practitioner sufficiently so that the Medicare contractor can
ensure that no payment is made to the physician/practitioner during the opt-out
period; and

• Be filed with all MACs who have jurisdiction over claims the
physician/practitioner would otherwise file with Medicare, and the initial 2-year
opt-out period will begin the date the affidavit meeting the requirements of 42
C.F.R §405.420 is signed, provided the affidavit is filed within 10 days after the
physician/practitioner signs his or her first private contract with a Medicare
beneficiary.

40.10 - Failure to Properly Opt Out

(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

A. A physician/practitioner fails to properly opt-out for any of the following
reasons:

• Any private contract between the physician/practitioner and a Medicare
beneficiary that was entered into before the affidavit described in §40.9 was filed
does not meet the specifications of §40.8; or

• The physician/practitioner fails to submit the affidavit(s) in accordance with
§40.9.