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Opting Out of Medicare

Federal regulations prohibit Medicare Advantage (MA) organizations, including BlueCross BlueShield of Western New York, from paying for services rendered by physicians or practitioners who have chosen to opt out of the Medicare program, except in limited circumstances.

A MA organization may contract only with physicians or practitioners who are eligible for participation in the Medicare program and who have not opted out of Medicare. (See Social Security Act § 42 CFR § 422.220.) Opting out is not the same as “non-participating.” Physicians or practitioners who opt out of Medicare cannot participate in our MA HMO and PPO networks.

BlueCross BlueShield will not cover any services provided by physicians/practitioners on or after the effective opt-out date, unless the service was eligible for payment as an emergency or urgently needed under applicable Medicare standards.

The Centers for Medicare and Medicaid Services (CMS) regulations for opt-out physicians or practitioners also require a “private contract” between the Medicare beneficiary and the physician or practitioner who opted out of Medicare. The private contract must include language such as, but not limited to, agreement that the Medicare beneficiary gives up Medicare payment — including payment from MA plans — for services furnished by the opt-out physician or practitioner, as well as to pay the physician/practitioner for services directly.

A physician or practitioner may cancel opt out by submitting written notice to the Medicare Administrative Contractor not later than 30 days before the end of the current two-year opt-out period. If a physician or practitioner wants early termination of their opt-out status, there are specific Medicare requirements that must be met timely and the physician or practitioner must not have previously opted out.

Physicians and practitioners must follow CMS rules regarding opting out of Medicare. The requirements and possible exceptions are outlined in the CMS Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, accessible online at cms.gov.

If your status with Medicare changes, you must notify us promptly by calling 1-800-666-4627. More information for New York State physicians and practitioners is available from the local Medicare Administrative Contractor, National Government Services, at ngsmedicare.com.

If you have any questions regarding this stat, please contact Provider Service at 1-800-950-0051 or (716) 884-3461

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