[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR405.415]



[Page 102]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 405_FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED--Table of 

Contents

 

                       Subpart D_Private Contracts

 

Sec. 405.415  Requirements of the private contract.



    A private contract under this subpart must:

    (a) Be in writing and in print sufficiently large to ensure that the 

beneficiary is able to read the contract.

    (b) Clearly state whether the physician or practitioner is excluded 

from Medicare under sections 1128, 1156, or 1892 or any other section of 

the Social Security Act.

    (c) State that the beneficiary or his or her legal representative 

accepts full responsibility for payment of the physician's or 

practitioner's charge for all services furnished by the physician or 

practitioner.

    (d) State that the beneficiary or his or her legal representative 

understands that Medicare limits do not apply to what the physician or 

practitioner may charge for items or services furnished by the physician 

or practitioner.

    (e) State that the beneficiary or his or her legal representative 

agrees not to submit a claim to Medicare or to ask the physician or 

practitioner to submit a claim to Medicare.

    (f) State that the beneficiary or his or her legal representative 

understands that Medicare payment will not be made for any items or 

services furnished by the physician or practitioner that would have 

otherwise been covered by Medicare if there was no private contract and 

a proper Medicare claim had been submitted.

    (g) State that the beneficiary or his or her legal representative 

enters into this contract with the knowledge that he or she has the 

right to obtain Medicare-covered items and services from physicians and 

practitioners who have not opted-out of Medicare, and that the 

beneficiary is not compelled to enter into private contracts that apply 

to other Medicare-covered services furnished by other physicians or 

practitioners who have not opted-out.

    (h) State the expected or known effective date and expected or known 

expiration date of the opt-out period.

    (i) State that the beneficiary or his or her legal representative 

understands that Medigap plans do not, and that other supplemental plans 

may elect not to, make payments for items and services not paid for by 

Medicare.

    (j) Be signed by the beneficiary or his or her legal representative 

and by the physician or practitioner.

    (k) Not be entered into by the beneficiary or by the beneficiary's 

legal representative during a time when the beneficiary requires 

emergency care services or urgent care services. (However, a physician 

or practitioner may furnish emergency or urgent care services to a 

Medicare beneficiary in accordance with Sec. 405.440.)

    (l) Be provided (a photocopy is permissible) to the beneficiary or 

to his or her legal representative before items or services are 

furnished to the beneficiary under the terms of the contract.

    (m) Be retained (original signatures of both parties required) by 

the physician or practitioner for the duration of the opt-out period.

    (n) Be made available to CMS upon request.

    (o) Be entered into for each opt-out period.