US · guidance
CMS Pub. 100-02, ch. 15, § 40.5
When a Physician or Practitioner Opts Out of Medicare
When a physician/practitioner opts-out of Medicare, Medicare covers no services provided by that
individual and no Medicare payment can be made to that physician or practitioner directly or on a capitated
basis. Additionally, no Medicare payment may be made to a beneficiary for items or services provided
directly by a physician or practitioner who has opted out of the program.
EXCEPTION: In an emergency or urgent care situation, a physician/practitioner who opts-out may treat a
Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such
a situation, the physician/practitioner may not charge the beneficiary more than what a nonparticipating
physician/practitioner would be permitted to charge and must submit a claim to Medicare on the
beneficiary’s behalf. Payment will be made for Medicare covered items or services furnished in emergency
or urgent situations when the beneficiary has not signed a private contract with that physician/practitioner.
(See §40.28.)
Under the statute, the physician/practitioner cannot choose to opt-out of Medicare for some Medicare
beneficiaries but not others; or for some services but not others. The physician/practitioner who chooses to
opt-out of Medicare may provide covered care to Medicare beneficiaries only through private contracts.
Medicare will make payment for covered, medically necessary services that are ordered or certified by a
physician/practitioner who has opted out of Medicare if the ordering or certifying physician/practitioner has
acquired a National Provider Identifier (NPI), reports his/her Social Security Number, has a valid opt-out
affidavit on file with his or her Medicare Administrative Contractor (MAC), is of a specialty that is eligible
to order and certify, and provided that the services are not furnished by another physician/practitioner who
has also opted out. For example, if an opt-out physician/practitioner admits a beneficiary to a hospital,
Medicare will reimburse the hospital for medically necessary care.
History
(Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
f6fce95df5440ceb20c7f272b7f2fe50dfa26b3fe89b404978868fcc18a7c0de
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.