Section 1802 of the Social Security Act, as amended by Section 4507 of the Balanced Budget Act of 1997, permits a doctor or practitioner to "opt-out" of Medicare and enter into private contracts with Medicare beneficiaries if specific requirements are met. This is not the same as "non-participating". By "opting-out", a doctor or practitioner has decided not to provide services through the Medicare program and not bill for any services or supplies they provide to any Medicare beneficiary for a period of at least 2 years. Under a private contract:
A private contract applies only to the services provided by the doctor or practitioner who asked you to sign it. Therefore, you can seek the services of other Medicare providers (par or non-par) and bill Medicare. You cannot be asked to sign a private contract when you are facing an emergency or urgent health situation. In this case, the doctor or practitioner would submit a claim to Medicare for reimbursement. When Medicare refers to a doctor or supplier as either "participating" or "non-participating", it relates to how the doctor or supplier is paid. It does not affect whether the services they provide are covered. When a doctor or supplier "participates", he/she agrees to accept assignment. In other words, he/she will accept the payment approved by Medicare as payment in full. When a doctor or supplier is "non-participating", he/she does not accept assignment except in some individual cases. A doctor or supplier who does not accept assignment can charge an additional amount over the Medicare approved amount. That extra amount is called the "limiting charge". The Federal limiting charge amount is 15 percent above the Medicare approved amount. The Federal limit applies to Connecticut, Delaware and New Jersey in our service area. In New York, state law sets the limiting charge at 5 percent and in Massachusetts the law sets the limit at zero percent. A doctor or supplier who charges a patient more than the limiting charge must refund the difference. You might find it helpful to talk with someone in your State Health Insurance Assistance Program before signing a private contract with any doctor. They can also help you if you have further questions about the limiting charge amounts applied in your state.
The following search includes the names, addresses, and UPIN numbers of those doctors/practitioners who have decided to "opt-out" of Medicare.
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