If your doctor opted out of Medicare, neither Medicare nor any Medicare Advantage plan pays for the care that doctor gives you under a private contract. The one opening is emergency or urgent care from an opted-out doctor you never signed a private contract with, and a doctor who hasn't been excluded from Medicare must bill Medicare for that care. "What if my doctor opted out of Medicare?" is a question many families only ask once the paper is already in their hands, and it can feel like a door closing on a doctor you have trusted for years. You still have real choices, and the federal rules spell out exactly what the contract has to say before you decide.

In This Guide

What Does It Mean When a Doctor Opts Out of Medicare?

Maybe you only found out at the front desk, or maybe you found the signed form in a parent's folder of papers. Either way, "opted out" means something specific. The federal rules live in Title 42 of the Code of Federal Regulations (CFR), at 42 CFR Part 405, Subpart D, and the Centers for Medicare & Medicaid Services (CMS) explains them in Chapter 15 of its Medicare Benefit Policy Manual.

According to the CMS Medicare Benefit Policy Manual, when a physician or practitioner opts out of Medicare, Medicare covers no services provided by that individual, and no Medicare payment can be made to a beneficiary for items or services that the opted-out provider furnishes directly. Under 42 CFR 405.425(b), a doctor who has opted out of Medicare may not furnish any item or service Medicare would otherwise cover to any Medicare beneficiary except through a private contract, with the exception of emergency or urgent care. In these rules, a "beneficiary" is a person enrolled in Medicare Part B (see our Part B guide).

A Medicare opt-out lasts for a 2-year period that begins on the date the doctor signs an opt-out affidavit, and it continues into each following 2-year period unless the doctor properly cancels it, under 42 CFR 405.400. The CMS Medicare Benefit Policy Manual says valid opt-out affidavits signed on or after June 16, 2015, renew automatically every 2 years. Under 42 CFR 405.445(a), a doctor who wants to stop opting out must send written notice to each Medicare Administrative Contractor (MAC) it would otherwise bill, no later than 30 days before the current 2-year opt-out period ends.

Only certain providers can opt out of Medicare. Under 42 CFR 405.400, the physicians who may opt out are doctors of medicine, doctors of osteopathy, dentists (doctors of dental surgery or dental medicine), podiatrists and optometrists who are legally authorized to practice in their state. Under 42 CFR 405.410, a non-participating physician or a practitioner may opt out of Medicare at any time, while a participating physician may opt out only at the start of a calendar quarter, with the affidavit submitted at least 30 days before that quarter begins.

What Must a Private Contract Say Before You Sign It?

This is the part to slow down for. A Medicare private contract is not a routine intake form, and the regulation at 42 CFR 405.415 lists everything it has to contain. Hold the paper next to this list. Under 42 CFR 405.415, a Medicare private contract must state:

  • Whether the doctor or practitioner is excluded from Medicare under sections 1128, 1156 or 1892 or any other section of the Social Security Act.
  • That you (or your legal representative) accept full responsibility for paying the doctor's charge for all services the doctor furnishes.
  • That you understand Medicare limits do not apply to what the doctor may charge.
  • That you agree not to submit a claim to Medicare and not to ask the doctor to submit one.
  • That you understand Medicare will not pay for any item or service from this doctor that Medicare would otherwise have covered without the contract.
  • That you are signing knowing you have the right to get Medicare-covered care from doctors who have not opted out, and that you are not required to sign private contracts with other doctors.
  • The expected or known start date and end date of the doctor's current 2-year opt-out period.
  • That you understand Medigap plans do not, and other supplemental plans may choose not to, pay for items and services Medicare does not pay for.

Under 42 CFR 405.415, the Medicare private contract itself must also meet these conditions:

  • It is in writing, in print large enough for you to read.
  • It is signed by you (or your legal representative) and by the doctor.
  • It is not signed while you need emergency or urgent care.
  • It is given to you, or a photocopy is, before any item or service is furnished under it.
  • The doctor keeps it, with both original signatures, for the full 2-year opt-out period and makes it available to CMS on request.
  • It is signed again for each new 2-year opt-out period.

That last item matters if you have seen the same doctor for years. The CMS Medicare Benefit Policy Manual says that when a 2-year opt-out period ends, an opted-out doctor must enter into new private contracts with each Medicare patient for the new 2-year period. Because a valid Medicare private contract must show the start and end dates of the doctor's current opt-out period, the contract itself tells you whether that doctor has opted out and for how long.

When Can't a Doctor Ask You to Sign One?

Nobody should be asked to sign away their Medicare coverage while in pain or in danger, and the rules agree. Under 42 CFR 405.415(k), a Medicare private contract may not be entered into by a patient or the patient's legal representative while the patient needs emergency care services or urgent care services. Under 42 CFR 405.440(a), a doctor who has opted out of Medicare does not need a private contract to give a Medicare patient emergency or urgent care.

Both terms have precise definitions in 42 CFR 405.400:

  • Emergency care services: inpatient or outpatient hospital services needed to prevent death or serious impairment of health that, because of the danger to life or health, require the most accessible hospital available and equipped to provide them.
  • Urgent care services: services for a person who needs care within 12 hours to avoid the likely onset of an emergency medical condition.

The CMS Medicare Benefit Policy Manual gives an ear infection with significant pain as an example of a condition CMS would view as needing urgent treatment.

What Happens If You Need Emergency or Urgent Care From an Opted-Out Doctor?

The answer depends on one thing: whether you signed a private contract with that doctor before the emergency started.

If you never signed a private contract with the opted-out doctor, 42 CFR 405.440(b) says a doctor who has not been excluded from Medicare must submit a claim to Medicare for the emergency or urgent care. For emergency or urgent care given to a patient with no private contract, an opted-out physician may collect no more than the Medicare limiting charge, and an opted-out practitioner may collect no more than the Medicare deductible and coinsurance, according to the CMS Medicare Benefit Policy Manual. Under 42 CFR 405.440(d), Medicare may pay for emergency or urgent care from an opted-out doctor when the care is furnished and the claim is filed in accordance with 42 CFR 405.440. Our guide to Part B excess charges explains how the limiting charge works.

If you already signed a private contract with the opted-out doctor before the emergency or urgent condition began, 42 CFR 405.440(c) says the emergency or urgent care is furnished under the terms of that private contract. In plain terms, the emergency exception protects patients who had no private contract with the doctor, not patients who had already signed one.

Does Medigap or Medicare Advantage Pay If Your Doctor Opted Out of Medicare?

This is usually the hardest question for families, because many people bought a supplement precisely so they would never face a full bill. Under 42 CFR 405.415(i), every Medicare private contract must state that the patient understands "Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare." Before you sign, check with your Medigap insurer or other supplemental plan about what it will do (our Medigap guide explains how these policies work).

The CMS Medicare Benefit Policy Manual says no Medicare primary or secondary payments will be made for items and services an opted-out doctor furnishes under a private contract, even where Medicare would otherwise be the secondary payer.

If you are in a Medicare Advantage plan, the rule is the same. Under 42 CFR 405.455(b), a Medicare Advantage organization must make no payment, directly or indirectly, for Medicare-covered services furnished to a Medicare patient by a doctor who has opted out of Medicare. Under 42 CFR 405.455(c), a Medicare Advantage organization may pay an opted-out doctor who furnishes emergency or urgent care to a patient who has not previously signed a private contract with that doctor. Our comparison of Original Medicare and Medicare Advantage covers the broader differences between the two.

How Is an Opted-Out Doctor Different From a Non-Participating Doctor?

The two labels get blurred constantly, and the difference is large. When a non-participating provider doesn't accept assignment on your claim, Medicare still pays, and it pays you directly, while a doctor who has opted out of Medicare is prohibited from submitting claims to Medicare except for certain emergency or urgent care.,

Question Non-participating provider who doesn't accept assignment on the claim Doctor who opted out of Medicare
Does Medicare pay? Yes; Medicare pays you directly, usually 80% of the Medicare-approved amount No, except emergency or urgent care for a patient with no prior private contract
Is there a cap on what you can be charged? Yes; up to 15% over the Medicare-approved amount (the limiting charge) No Medicare limit under a private contract

Under 42 CFR 405.425(e), a physician who has opted out of Medicare is not subject to the Medicare limiting charge, except for emergency or urgent care furnished under 42 CFR 405.440. For the full breakdown of provider statuses and what each one can bill, see our guide to Medicare Part B excess charges.

Can an Opted-Out Doctor Still Order Tests, Prescriptions or Hospital Care?

Often, yes, and that can soften the blow. Under 42 CFR 405.425(i), an opted-out doctor who has not been excluded from Medicare and whose Medicare enrollment has not been revoked may order, certify the need for, prescribe, or refer a patient for Medicare-covered items, services and drugs, as long as that doctor is not paid for them. The CMS Medicare Benefit Policy Manual says Medicare will pay for covered, medically necessary services ordered or certified by an opted-out doctor who meets the conditions listed in that manual, provided the services are not furnished by another doctor who has also opted out. For example, the manual says that if an opted-out doctor admits a patient to a hospital, Medicare will reimburse the hospital for medically necessary care.

A Medicare private contract is also a different document from an Advance Beneficiary Notice (ABN). The CMS Medicare Benefit Policy Manual says opted-out doctors must not use Advance Beneficiary Notices, because they use private contracts for any item or service that is or may be covered by Medicare, except emergency or urgent care. According to the same manual, an ABN is used when a provider believes Medicare will not pay, while a private contract is used for services Medicare covers and might pay for if a claim were submitted.

What If the Doctor Never Had You Sign a Contract?

Sometimes families discover the opt-out only when a bill arrives and there is no signed contract anywhere. The rules treat that seriously. Under 42 CFR 405.435, an opted-out doctor "fails to maintain opt-out" by, among other things, not entering into private contracts with Medicare patients for services Medicare would otherwise cover, or by using contracts that do not meet the requirements of 42 CFR 405.415.

When an opted-out doctor fails to maintain opt-out, 42 CFR 405.435(b) says all of that doctor's private contracts with Medicare patients are void, the opt-out is nullified, and the doctor must submit claims to Medicare for all Medicare-covered services, for the rest of the opt-out period. When an opted-out doctor fails to maintain opt-out, a physician becomes subject to the Medicare limiting charge, and a practitioner may collect nothing from the patient beyond the applicable deductible and coinsurance, under 42 CFR 405.435(b). The 42 CFR 405.435(b) consequences of failing to maintain Medicare opt-out, including voided private contracts, a nullified opt-out and those charge limits, do not apply if the doctor shows good-faith efforts to maintain opt-out, including refunds of amounts above the charge limits, within 45 days of a notice of the violation from the Medicare Administrative Contractor, under 42 CFR 405.435(d). In plain terms, if an opted-out doctor billed you without a valid private contract, that doctor may have to file your claims with Medicare and stay within Medicare's charge limits for the rest of the opt-out period, unless the doctor shows those good-faith efforts within 45 days of the contractor's notice of the violation.

Your own claim has a time window. Under 42 CFR 405.435(c), Medicare may pay claims a patient submits for non-emergency services from an opted-out doctor who never signed a private contract with that patient, for services furnished no later than 15 days after the date of a notice from Medicare's contractor that the doctor has opted out. The CMS Medicare Benefit Policy Manual says that if the patient signed a private contract with the opted-out doctor for the services, or received the doctor's services 15 days after the date of a Medicare contractor notice that the doctor has opted out, no Medicare payment may be made. So if you never signed a private contract, the date of a Medicare contractor notice that your doctor has opted out is a cutoff: under 42 CFR 405.435(c) and the CMS Medicare Benefit Policy Manual, Medicare can pay your claims only for that doctor's non-emergency services furnished no later than 15 days after that notice.

If Medicare decides it cannot pay you for an opted-out doctor's services, that decision has a formal status. Under 42 CFR 405.450(b), a CMS determination that no payment can be made to a patient for the services of a physician who has opted out of Medicare is an "initial determination" for purposes of 42 CFR 405.924. Our guide to Medicare appeals explains how Medicare decisions can be challenged.

What Are Your Options?

You don't have to decide on the spot, and you don't have to decide alone. These steps follow the order most families work through:

  1. Ask for the contract before your visit. A Medicare private contract must be given to you, or a photocopy of it, before any service is furnished under it, so you can read it at home first.
  2. Check it against the 42 CFR 405.415 list above. Look especially for the opt-out period's start and end dates and the statement about Medigap plans.
  3. Decide whether to see a doctor who hasn't opted out. Signing one Medicare private contract does not prevent you from getting Medicare-covered care from other doctors who have not opted out, according to the CMS Medicare Benefit Policy Manual.
  4. If you sign, plan for the full bill. Under a Medicare private contract, you accept full responsibility for paying the doctor's charge, and Medicare limits do not apply to what the doctor may charge. Our Medicare costs guide can help you weigh that against your other Medicare costs.
  5. Keep ordered care in Medicare. Ask the opted-out doctor to send tests, prescriptions and referrals to providers who haven't opted out, since Medicare can pay those furnishing providers when the ordering doctor meets the conditions CMS lists in its Medicare Benefit Policy Manual.
  6. Get a second set of eyes. Your State Health Insurance Assistance Program (SHIP) is one place to ask questions; our guide to SHIP counseling explains how to reach it.

Frequently Asked Questions

Can my doctor opt out of Medicare for some patients only?

No. The CMS Medicare Benefit Policy Manual says that under the statute, a physician or practitioner cannot opt out of Medicare for some Medicare beneficiaries but not others, or for some services but not others.

Can a doctor cancel opt-out early and refund me?

Sometimes. Under 42 CFR 405.445(b), a doctor may end opt-out early only if the doctor has never opted out of Medicare before and notifies every Medicare Administrative Contractor it filed an opt-out affidavit with no later than 90 days after the start of the first 2-year opt-out period. A doctor who ends opt-out early under 42 CFR 405.445(b) must refund each privately contracted patient everything collected above the Medicare limiting charge (for physicians) or the deductible and coinsurance (for practitioners), and must tell those patients they have the right to have claims filed with Medicare for services during the opt-out.

Does opt-out apply to services Medicare never covers?

No private contract is needed for those. The CMS Medicare Benefit Policy Manual says that because Medicare's rules do not apply to items or services that are categorically not covered by Medicare, a private contract is not needed to furnish them, and it gives hearing aids as an example.

Can a nurse practitioner, therapist or counselor opt out of Medicare?

Some can. Under 42 CFR 405.400, the practitioners who may opt out of Medicare are physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical psychologists, clinical social workers, marriage and family therapists, mental health counselors, and registered dietitians or nutrition professionals.

Can a chiropractor or physical therapist opt out of Medicare?

No. The CMS Medicare Benefit Policy Manual says chiropractors may not opt out of Medicare, and that physical therapists and occupational therapists in independent practice cannot opt out either, because neither group falls within the opt-out law's definitions.

Learn More

MedicareWhat Are Medicare Part B Excess Charges?A Medicare Part B excess charge is up to 15% extra a provider who doesn't accept assignment can bill. Here's who pays it and how Medigap covers it. MedicareFree Medicare Counseling Through SHIPSHIP gives free Medicare counseling. Federal law requires its counselors to have no conflict of interest, and ACL bars licensed insurance agents. Find yours. MedicareMedigap ExplainedMedigap (Medicare Supplement) explained: how the standardized A-N plans work, Plan G vs Plan N, closed C and F plans, and the 6-month guaranteed-issue window. MedicareAdvance Beneficiary NoticeAn Advance Beneficiary Notice (ABN) is the form your provider gives you before a service Medicare may not cover. What signing it means and your appeal rights. MedicareMedicare AppealsA Medicare denial isn't final. Here's how to appeal one through all five levels, with 2026 deadlines, dollar thresholds, and the fast track for urgent care. MedicareMedicare Part BMedicare Part B covers doctors, outpatient care and equipment. In 2026 it costs $202.90 a month plus a $283 deductible, then usually 20% of the approved amount.

Find personalized help reading a Medicare private contract with Brevy's care navigator at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

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