Also known as: Opt-out provider, Medicare opt-out affidavit, Opted out of Medicare
Key facts
- Legal basis
- Section 1802(b) of the Social Security Act; 42 CFR 405 Subpart D
- Filed with
- The Medicare Administrative Contractor (MAC)
- Opt-out period
- 2 years, renewing automatically unless canceled
- Scope
- All Medicare patients, not one patient at a time
- Public data
- CMS publishes an opt-out affidavits dataset
What is Medicare opt-out?
Most clinicians who see Medicare patients are enrolled in Medicare and bill it, either as participating or non-participating providers. Opt-out is a third path. A physician or eligible practitioner files an opt-out affidavit, and from then on neither the clinician nor the patient bills Medicare for the services they provide.
Instead, the clinician signs a private contract with each Medicare patient. The patient agrees to pay the clinician directly, accepts that Medicare will not pay, and accepts that the Medicare limiting charge does not apply.
How opt-out works
The main rules are set in regulation and enforced by the MACs:
- Eligible clinicians include physicians, dentists, podiatrists, optometrists and certain non-physician practitioners such as nurse practitioners and physician assistants.
- Since 2015, opt-out periods renew automatically every two years unless the clinician cancels at least 30 days before the period ends.
- Opt-out covers all Medicare patients. A clinician cannot opt out for some Medicare patients and bill Medicare for others.
- Emergency or urgent care for a patient without a private contract can still be billed to Medicare under specific conditions.
- Opted-out clinicians can still order and refer services, such as labs and imaging, that Medicare then pays to the furnishing provider.
Why opt-out status matters
Opt-out is common in cash-based specialties such as psychiatry, concierge primary care and some behavioral health practices. For patients, it means out-of-pocket costs with no Medicare reimbursement. For analysts, opted-out clinicians are invisible in Medicare claims data even when they treat many older patients, so claims-based market sizing undercounts them.
Sales and recruiting teams use opt-out status as a signal of practice model. A clinician with an active opt-out affidavit is unlikely to respond to a pitch built around Medicare billing or Medicare quality programs.