What it means when a physician ‘opts out’ of Medicare; Covering; The Bases
I am 65 and just started my Medicare. My gynecologist notified me that she has "opted out of Medicare," and her services are not covered by Medicare. In order to continue seeing my gynecologist, I must sign a private contract. I have a long-standing patient/doctor relationship with this provider and do not want to change providers. I am disturbed that Medicare will not pay. I need more information on this situation.
Many obstetricians/gynecologists have "opted out" of Medicare. This is simply because the majority of their patients are women who are of child-bearing age and are not covered by Medicare.
In many cases, when a woman turns 65, she is informed by her OB/GYN office that the provider has elected to "opt out" of Medicare. Opting out is permitted by Medicare; however, there are strict rules concerning it.
The physician must file an affidavit with Medicare stating the provider's decision to opt out of Medicare. The provider must notify, in writing, all Medicare-enrolled patients of the provider's opt-out status. If a person with Medicare wants to continue to receive health care services from the provider, they sign a private contract with the provider.
The private contract must clearly state that the physician is excluded from Medicare under the opt-out rules. The contract must clearly state that Medicare will not pay for services rendered by the opt-out provider (unless care is provided in an emergency situation). The contract must clearly state that patient will be responsible for payment of the opt-out physician's charges.
As you state, you have had a long-standing patient/doctor relationship. If you want to continue seeing your gynecologist, you will need to enter into a private contact with your doctor. You will be responsible for all costs. Medicare will not reimburse you.
If your secondary insurance is a Medigap plan, your Medigap plan will not pay for the charges. If your secondary insurance is something other than a Medigap, contact your secondary insurance to see if they will cover a Medicare opt-out provider. Also check with your provider to see if she accepts this secondary insurance.
Many women facing this dilemma consider finding a provider who will accept Medicare. While it is a difficult decision to change providers, many people simply cannot afford to pay out-of-pocket. Medicare offers a list of providers who accept Medicare online at www.medicare.gov or by calling 1-800-MEDICARE.
My gynecologist has opted out of Medicare and does not bill Medicare. I have a secondary insurance that might reimburse for my gynecological care. However, my secondary insurance requires I provide them a Medicare denial before the secondary insurance will pay. If the doctor does not bill Medicare, how do I get a Medicare denial?
You describe one of the few instances where you, the patient, would be advised to submit a claim to Medicare. Most providers are required, by law, to submit claims on their patient's behalf. However, providers who have officially "opted out" of Medicare do not submit claims to Medicare.
You may submit the claim to Medicare. Medicare will deny the claim since your provider has an opt-out status. You could then submit the Medicare denial to your secondary insurance for their consideration. You may access a Medicare claim form online at www.medicare.gov (click on tab for Forms, Help and Resources) or call 1-800-MEDICARE.
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