[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: 42CFR405.420]



[Page 102-103]

 

                         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. 405.420  Requirements of the opt-out affidavit.



    An affidavit under this subpart must:

    (a) Be in writing and be signed by the physician or practitioner.

    (b) Contain the physician's or practitioner's full name, address, 

telephone number, national provider identifier (NPI) or billing number, 

if one has been assigned, uniform provider identification number (UPIN) 

if one has been assigned, or, if neither an NPI nor a UPIN has been 

assigned, the physician's or practitioner's tax identification number 

(TIN).

    (c) State that, except for emergency or urgent care services (as 

specified in Sec. 405.440), during the opt-out period the physician or 

practitioner will provide services to Medicare beneficiaries only 

through private contracts that meet the criteria of paragraph Sec. 

405.415 for services that, but for their provision under a private 

contract, would have been Medicare-covered services.

    (d) State that the physician or practitioner will not submit a claim 

to Medicare for any service furnished to a Medicare beneficiary during 

the opt-



[[Page 103]]



out period, nor will the physician or practitioner permit any entity 

acting on his or her behalf to submit a claim to Medicare for services 

furnished to a Medicare beneficiary, except as specified in Sec. 

405.440.

    (e) State that, during the opt-out period, the physician or 

practitioner understands that he or she may receive no direct or 

indirect Medicare payment for services that he or she furnishes to 

Medicare beneficiaries with whom he or she has privately contracted, 

whether as an individual, an employee of an organization, a partner in a 

partnership, under a reassignment of benefits, or as payment for a 

service furnished to a Medicare beneficiary under a Medicare+Choice 

plan.

    (f) State that a physician or practitioner who opts-out of Medicare 

acknowledges that, during the opt-out period, his or her services are 

not covered under Medicare and that no Medicare payment may be made to 

any entity for his or her services, directly or on a capitated basis.

    (g) State a promise by the physician or practitioner to the effect 

that, during the opt-out period, the physician or practitioner agrees to 

be bound by the terms of both the affidavit and the private contracts 

that he or she has entered into.

    (h) Acknowledge that the physician or practitioner recognizes that 

the terms of the affidavit apply to all Medicare-covered items and 

services furnished to Medicare beneficiaries by the physician or 

practitioner during the opt-out period (except for emergency or urgent 

care services furnished to the beneficiaries with whom he or she has not 

previously privately contracted) without regard to any payment 

arrangements the physician or practitioner may make.

    (i) With respect to a physician who has signed a Part B 

participation agreement, acknowledge that such agreement terminates on 

the effective date of the affidavit.

    (j) Acknowledge that the physician or practitioner understands that 

a beneficiary who has not entered into a private contract and who 

requires emergency or urgent care services may not be asked to enter 

into a private contract with respect to receiving such services and that 

the rules of Sec. 405.440 apply if the physician furnishes such 

services.