Page 40 - Medicare Benefit Policy Manual

The Medicare contractor must update the system files so that it may timely pay
participating physicians and practitioners at the correct payment amounts in effect for that
part of the fee schedule year before they opt out and to pay them as nonparticipating for
emergency or urgent care as of their opt out effective date.

40.17 - Participating Physicians and Practitioners

(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

Participating physicians and practitioners may opt out if they file an affidavit that meets
the criteria and which is received by the Medicare contractor at least 30 days before the
first day of the next calendar quarter showing an effective date of the first day in that
quarter (i.e., January 1, April 1, July 1, October 1). They may not provide services under
private contracts with beneficiaries earlier than the effective date of the affidavit.

The 30-day notice is required to allow sufficient time for the Medicare contractor to
accomplish the appropriate system file updates before the effective date. The Medicare
contractor must make participating physician status changes no less frequently than at the
beginning of each calendar quarter. Therefore, participating physicians or practitioners
must provide the Medicare contractor with 30 days notice that they intend to opt out at
the beginning of the next calendar quarter.

Participating physicians or practitioners may sign private contracts only after the
effective date of affidavits filed in accordance with §40.9. They may not provide services
under private contracts with beneficiaries earlier than the effective date of the affidavit.
It is necessary to treat nonparticipating physicians or practitioners differently from
participating physicians or practitioners in order to assure that participating physicians or
practitioners are paid properly for the services they furnish before the effective date of the
affidavit.

Participating physicians or practitioners are paid at the full fee schedule for the services
they furnish to Medicare beneficiaries. However, the law sets the payment amount for
nonparticipating physicians or practitioners at 95 percent of the payment amount for
participating physicians or practitioners.

Participating physicians or practitioners who opt out are treated as nonparticipating
physicians or practitioners as of the effective date of the opt-out affidavit. When a
participating physician/practitioner opts out of Medicare, the Medicare contractor must
pay the physician/practitioner at the higher participating physician/practitioner rate for
services rendered in the period before the effective date of the opt-out; and at the
nonparticipating rate for services rendered on and after the opt-out date.

40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)

If a physician/practitioner chooses to opt-out of Medicare, it means that the physician/
practitioner opts-out for all covered items and services that he or she furnishes.