Medicare Opt Out - Paying Everything Out-of-Pocket

By: Meredith Miller
Published: Tuesday, September 18 2018
Last Updated: 4 years ago

With things changing so much in the medical and insurance sectors, it can be hard to keep up with everything. One of those things is Medicare opt out. It can be a little confusing at first, but it's easy to understand after reading up on it. Keep reading to learn more about Medicare opt out and what an opt out private contract is.

What Does It Mean To Opt Out Of Medicare?

Medicare opt out refers to a contract between a medical provider, beneficiary, and Medicare which states that neither the medical provider or beneficiary won’t file a claim with Medicare. Instead, the medical provider, either a doctor or physician, will bill the beneficiary directly, and the beneficiary will pay entirely out-of-pocket.

Medical providers have to choose to opt out when they do, they need to file an Opt Out Affidavit with Medicare. After the affidavit is submitted, providers are also required to keep a private contract with all their Medicare beneficiary patients and keep the contract on file for 2 years.

In order for a provider to opt back into Medicare, they must file a cancel renewal letter 30 days before their 2 years opt out cycle ends. If they are late submitting their cancel renewal letter, they will be opted out of Medicare for an additional 2 years.

Why Providers Choose To Opt Out

There are a few reasons why providers might choose to participate in Medicare opt out options. The biggest reason is that the provider wants to handle everything in-house. They don't want to deal with any outside companies.

Another reason is that medical professionals can see Medicare patients under private contracts. This means that they don't have to deal with everything that comes with Medicare, such as the rules and stipulations.

One final reason why a provider might opt out is that they will be able to charge patients what they want. For example, they might have to charge a Medicare patient $200 for a certain service because the rules say so. If they aren't dealing with Medicare, they'll be able to charge less than that and save their patients a little money. They could also choose to charge more for certain services.

Private Contract

When looking at this aspect of the medical field, you need to know what an opt out the private contract is. A private contract is just a contract between a physician and a Medicare patient. This contract lets patients know that physicians can charge more or less of what Medicare requires.

These contracts make it so medical professionals don't have to deal with Medicare at all. Medicare won't pay the doctor and they won't help the patient pay. One thing about the contract, though, is that they can't charge a different amount than they stated in the contract.

Opt Out Vs. Non-Participating

It’s also important to understand the difference between opt out and non participating Medicare providers. Opt out means that the provider has to agree to several terms and non-participating means that the provider can just choose to not accept Medicare.

Most of the medical professionals that choose to not participate are the ones that aren't eligible to actually opt out, such as chiropractors. There isn't anything that says providers have to accept Medicare, but they have to realize that they might not get paid for services if the patient has to pay out-of-pocket.

Providers Who Are Eligible To Opt Out Of Medicare

In order for Medicare providers to opt out, they have to be practicing medicine in certain areas. They also need to agree and sign an opt out private contract. The providers who are eligible are listed below.

  • Medicine doctors
  • Osteopathy doctors
  • Dental surgery and medicine doctors
  • Podiatric doctors
  • Physician assistants
  • Clinical nurses
  • Nurse practitioners
  • Certified registered nurse anesthetists
  • Certified midwives
  • Clinical social workers
  • Registered dieticians and nutrition professionals

Medical Providers Not Eligible

On the other hand, some Medicare providers in certain areas don't have the option to opt out. Even if they are willing to sign an opt out private contract, they don't have the option to do so. The list of doctors not eligible is much shorter than those who are and they are listed below.

  • Chiropractors
  • Anesthesiologist assistant
  • Speech Language Pathologist
  • Physical and Occupational therapists
  • Any profession that can't be enrolled in Medicare

Are There Any Benefits To Seeing A Provider Who Opted Out?

The main benefit of seeing a provider who has opted out is that you could end up paying less for services. Medicare has a certain amount that providers have to bill per service. If they aren't dealing with Medicare, the doctors can charge what they want.

The other huge benefit of seeing one of these doctors is that you don't have to wait a long time for the billing process. You no longer have to sit around wondering how much of your bill was paid. You can just pay it and be done!