AFFIDAVIT TO OPT OUT OF MEDICARE Preview on Page 1

AFFIDAVIT TO OPT OUT OF MEDICARE 2026

The document outlines the process for physicians and practitioners to opt out of Medicare by filing an affidavit with the Medicare carrier. It specifies deadlines for submission, terms of the opt-out period, and conditions under which services can be provided to Medicare beneficiaries through private contracts. The affidavit must be filed within 10 days of entering a private contract and includes acknowledgment of various terms regarding service provision and payment during the opt-out period.

Here's how it works

01. Edit your form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.

Definition & Meaning

An affidavit to opt out of Medicare is a formal declaration used by healthcare providers who decide not to participate in the Medicare program. This legal document must be filed by any physician or practitioner who wishes to provide services to Medicare beneficiaries under a private contract. By opting out, they acknowledge that they will not bill Medicare for any services provided to these patients during the opt-out period, thus establishing a direct payment contract with their clients instead.

Steps to Complete the Affidavit to Opt Out of Medicare

Acquire the form: Obtain the affidavit form from the Medicare administrative contractor (MAC) servicing your area.
Complete personal information: Fill in your name, specialty, and practice details accurately.
Acknowledge terms and conditions: Carefully read and agree to the terms which outline your responsibilities during the opt-out period.
Indicate the opt-out period: Specify the period for which you intend to opt-out, typically two years from the date of filing.
Sign and notarize the affidavit: Affix your signature in the presence of a notary public to validate the document.
Submit to the appropriate MAC: Send the completed and notarized form to your Medicare administrative contractor within the required deadline.

Why Should You Use the Affidavit to Opt Out of Medicare

Opting out of Medicare using this affidavit allows physicians greater flexibility in managing their practice and financial agreements with patients. By entering into private contracts, practitioners can set their fees without adhering to the Medicare fee schedule, thus tailoring services to meet both their financial needs and the preferences of their patients. This option is especially beneficial for practitioners in niche specialties or those seeking personalized financial arrangements with their patients.

Filing Deadlines / Important Dates

The affidavit must be filed within ten days of entering into a private contract with the first Medicare beneficiary. Failure to comply with this timeline results in the default participation in Medicare, rendering the private contract null and void. Additionally, practitioners must renew their decision to opt-out every two years, adhering to the same deadline requirements to maintain their status.

Key Elements of the Affidavit to Opt Out of Medicare

Declaration of opt-out: An explicit statement of the practitioner's intent to opt-out of the Medicare program.
Private contract acknowledgment: Confirmation that a private contract will be in place with each Medicare patient, stipulating payment terms directly.
Two-year commitment: An understanding that the opt-out applies for two consecutive years unless retracted at the subsequent renewal phase.
No billing to Medicare: A commitment not to submit any claims to Medicare for services rendered to opt-out patients during the period.

Legal Use of the Affidavit to Opt Out of Medicare

This affidavit serves a legal purpose by formalizing the opt-out process, ensuring all parties involved understand the scope, limitations, and duration of the agreement. Compliance with the terms is essential for avoiding legal and financial repercussions. It aligns with U.S. federal laws governing Medicare participation and provides a clear legal framework for practices choosing this path.

Important Terms Related to the Affidavit to Opt Out of Medicare

Medicare Administrative Contractor (MAC): The regional entity responsible for processing claims and overseeing the Medicare program.
Private Contract: A formal agreement between a practitioner and a patient outlining services and payment structures outside of Medicare benefits.
Two-Year Opt-Out Period: The mandated duration of non-participation in Medicare following submission of the affidavit.
Provider Enrollment Chain and Ownership System (PECOS): The database where physicians and practices update their Medicare participation status.

Examples of Using the Affidavit to Opt Out of Medicare

For instance, a psychiatrist specializing in holistic treatment might opt to operate outside Medicare to offer personalized care packages, charging directly to patients. Similarly, a concierge medical practice may find the flexibility afforded by private contracts more conducive to their boutique service models.

Eligibility Criteria

Eligibility requires that the physician or practitioner is legally recognized within their field to offer services covered by Medicare. Furthermore, they must not be excluded or disqualified by the Department of Health and Human Services (HHS) or any equivalent federal authority from participating in healthcare programs.

Who Typically Uses the Affidavit to Opt Out of Medicare

Typically, physicians in private practice, psychiatrists, or specialists in personalized or boutique care benefit the most from opting out. This is common among practitioners who desire control over billing and patient care quality, aligning services with patient preferences and personal practice models.

How to Obtain the Affidavit to Opt Out of Medicare

Contact the respective MAC assigned to your state to request the necessary forms. Often, these forms can also be downloaded directly from the MAC's website. Ensure you have the most updated version to avoid processing delays.