Can You Opt Out of Medicare? Rules and Process Explained
Eligibility and Timing for Opting Out of Medicare
The Medicare opt-out process is only available to specific types of healthcare providers, making understanding eligibility criteria essential before proceeding. Physicians who qualify to opt out include doctors of medicine or osteopathy, dental surgeons or dentists, podiatrists, and optometrists. In addition, practitioners such as physician assistants, nurse practitioners, certified nurse midwives, clinical nurse specialists, clinical psychologists, clinical social workers, certified registered nurse anesthetists, and registered dietitians or nutrition professionals are eligible. It is important to note that all providers must be legally authorized to practice in their state and meet Medicare’s general requirements.
Certain provider categories are excluded from opting out. For instance, chiropractors are not allowed to opt out of Medicare. Similarly, home health agencies and facilities cannot participate in the opt-out program. Each provider must verify their eligibility by checking current and updated Medicare coverage requirements and state licensing regulations.
Timing for opt-out is also crucial. Providers can decide to opt out at any point during their practice, but the effect of opting out ties to when the opt-out affidavit and private contract are executed and filed. The two-year opt-out period commences on the date the first affidavit is filed, provided the filing deadline is met within 10 days of signing the first private contract. Missing this deadline can delay or void the opt-out, making attention to timelines paramount.
Providers should also be aware that opting out of Medicare means they cannot participate in any Medicare-related plan-this includes not just Original Medicare, but also Medicare Advantage and Managed Care Plans. For more context on these distinctions, you can review guidance about Original Medicare vs. Advantage Plans.
Step-by-Step Medicare Opt-Out Process for Providers
1. Initiate Private Contracts
The first action in the Medicare opt-out process is entering into private contracts with Medicare beneficiaries who will receive your services. These contracts must be fully executed before or at the same time you submit your opt-out affidavit. This approach ensures you and your patient(s) are clear on financial responsibility and coverage exclusions before care is delivered.
2. Submit the Opt-Out Affidavit
After the first private contract is signed, providers have 10 calendar days to submit an opt-out affidavit to the Centers for Medicare & Medicaid Services (CMS) and every applicable Medicare Administrative Contractor (MAC). This affidavit must include:
- Your full legal name, Social Security Number, Date of Birth, and National Provider Identifier (NPI)
- A clear statement that you will not submit any claims to Medicare for the duration of the opt-out period, except as required for emergency or urgent services
- An acknowledgment of forfeiting Medicare payment during the period
- An agreement to be bound by the terms in both the affidavit and associated private contracts
- An indication whether you wish to retain your ability to order, certify, or prescribe Medicare services or supplies
Most MACs offer downloadable standardized affidavit forms on their websites, which streamline compliance and ensure all regulatory requirements are met.
3. Obtain Beneficiary Signatures
Every time you provide non-emergent or non-urgent care to a Medicare beneficiary, a signed private contract must be executed before services commence. These agreements must be readable, explicit, and inform the patient that they are assuming full financial responsibility and forfeiting any Medicare coverage for the contracted services. Importantly, contracts are not required or enforceable for first-time urgent or emergency care of beneficiaries who haven’t previously executed a private agreement with the provider; in those cases, standard Medicare billing applies.
In addition, providers must keep the original signed contracts on file for the entire two-year opt-out period and make them available to CMS upon request.
Private Contracts with Medicare Beneficiaries: What’s Required
Private contracting is a cornerstone of the Medicare opt-out process. Under a private contract:
- The opt-out provider and the beneficiary agree the patient will pay the full cost of all services rendered
- No Medicare payments will be made for contracted services
- The beneficiary forfeits the ability to seek Medicare reimbursement for services or items covered by the contract
- The contract must specify the start and end dates of the provider’s opt-out period
It’s important to consider that Medicare and private insurance interactions are different for contracted services outside Medicare coverage, with no crossover claims allowed on services rendered under private contracts.
To protect patient understanding and compliance, the contract must be easy to read (large type font is recommended), straightforward in explaining risks, and transparent about payment obligations. Providers must never coerce, mislead, or selectively offer private contracting. One cannot opt out for select patients, time periods, or services-it is all or nothing.
There are emergency care exceptions. If a new patient requires urgent or emergent services and does not already have a private contract with the opted-out provider, the provider must submit a traditional Medicare claim rather than rely on the private contract exclusion.
Duration, Renewal, and Grace Period for Medicare Opt-Out
The Two-Year Opt-Out Period
Once the opt-out affidavit is successfully filed and the first private contract is signed, the opt-out period lasts exactly two years. This is a fixed term; providers may not opt out for less than, or more than, this two-year duration. Accurate recording of these dates is crucial for compliance, contract preparation, and managing patient expectations.
Automatic Renewal of Opt-Out Status
For affidavits filed after June 16, 2015, opt-out status automatically renews at the conclusion of each two-year cycle. Providers are no longer required to submit a new affidavit for each renewal period. However, if a provider wishes to return to Medicare participation, they must notify their MAC in writing at least 30 days before the upcoming opt-out renewal date. Failure to do so results in seamless continuation of opt-out status, often catching practitioners unaware, given the rarity of reminders from administrative contractors.
The 90-Day Grace Period for First-Time Opt-Outs
A significant regulatory concession allows first-time opt-out providers to voluntarily terminate their opt-out within a 90-day window from the initial filing date. To do this, the provider must notify the MAC in writing. Upon termination, any previous participatory Medicare enrollment is reactivated automatically, which may be crucial for practice transitions or correcting mistaken decisions. This grace period does not apply to opt-out renewals or providers already in a prior opt-out cycle.
For a point of reference, you can use resources to check your or your patients’ Medicare coverage status for current or future years.
How to Re-enroll in Medicare After Opting Out
Providers may choose to return to Medicare participation after an opt-out period ends, or during the grace period for first-time opt-outs. Re-enrollment is not automatic; you must take affirmative steps:
- Written Notice: Submit written notification to your MAC at least 30 days before your next scheduled opt-out renewal, indicating your intent to cancel opt-out status.
- Follow MAC Instructions: Each MAC may have specific forms or online portals for this process, so consult your local contractor’s resources for up-to-date procedures.
- Medicare Application: Complete the appropriate Medicare enrollment application via PECOS (the Provider Enrollment, Chain, and Ownership System) as required for your practitioner type. This step is necessary for reactivation of billing rights and participation status.
Providers aiming to offer or prescribe Part D drugs for Medicare Advantage enrollees must also re-establish Medicare enrollment. For additional insights on program eligibility and enrolling in Medicare Advantage (Part C), see guidance on enrolling in Medicare Part C.
Be mindful that providers who miss renewal cancellation deadlines will remain opted out for the next two-year cycle and may need to wait until the subsequent window to rejoin Medicare, absent a qualifying reason for early termination.
Frequently Asked Questions About Medicare Opt-Out for Providers
1. What is the difference between a participating and a non-participating physician when it comes to Medicare?
A participating physician has agreed to accept the Medicare-approved amount as full payment for services and always accepts assignment. By contrast, a non-participating physician still has an agreement with Medicare but may, in certain cases, charge patients up to 15% more than the Medicare-approved amount. However, once a provider completes the Medicare opt-out process, they become neither participating nor non-participating, but rather completely separate from all Medicare payment rules. For ideas about broader Medicare participation options, you can find further reading in our resource, How Does Medicare Work With Private Insurance?.
2. Can I selectively opt out for some services or some patients?
No. Federal law requires that opt-out covers all services and all Medicare beneficiaries for the specified provider during the two-year opt-out period. There is no option to opt out for only certain patients, services, or time periods.
3. May I opt out if I am not currently enrolled in Medicare?
Yes, you do not have to be currently enrolled in Medicare to initiate the opt-out process. However, you must meet all state and federal licensing requirements to be eligible. Opting out involves signing private contracts with Medicare beneficiaries and submitting an affidavit-regardless of prior Medicare participation status.
4. What happens if I provide urgent or emergency care to a Medicare beneficiary without a prior private contract?
In these cases, federal rules require that you bill Medicare for the services provided. The private contract exception does not apply to first-time emergent or urgent care. Future non-emergency services should still be delivered under a valid private contract if you remain opted out.
5. What must my private contract include?
Your private contract should: state clearly that neither you nor the patient will file Medicare claims for services; specify the start and end dates of the opt-out; specify the patient’s financial responsibility; and affirm that the patient waives Medicare coverage for contracted services. Retain the signed contract for all patients for the full duration of the opt-out period and provide it to CMS upon request.
6. How do I ensure compliance with renewal and re-enrollment requirements?
Mark your opt-out anniversary dates, give written notice to MACs on time if you wish to return to Medicare, maintain all required documentation, and consult your MAC for the most current procedural details. For updates and timelines about Medicare enrollment periods and deadlines, reference How to Enroll in Medicare Part C: 2026 Eligibility & Deadlines.
7. Can I continue to prescribe medications covered by Medicare Part D while opted out?
Yes, as long as you indicate in your opt-out affidavit your intent to order, certify, and prescribe services, including drugs. However, you must provide your Social Security Number, Date of Birth, and National Provider Identifier (NPI) to maintain prescribing privileges.
8. Where can I check the status of my or my patients’ current Medicare enrollment or coverage details?
Providers and beneficiaries alike can use available Medicare resources to check Medicare coverage, verify Part B enrollment, or review Medicare program participation for upcoming years.
