[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: 42CFR405.425]



[Page 103-104]

 

                         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. 405.425  Effects of opting-out of Medicare.



    If a physician or practitioner opts-out of Medicare in accordance 

with this subpart for the 2-year period for which the opt-out is 

effective, the following results obtain:

    (a) Except as provided in Sec. 405.440, no payment may be made 

directly by Medicare or by any Medicare+Choice plan to the physician or 

practitioner or to any entity to which the physician or practitioner 

reassigns his right to receive payment for services.

    (b) The physician or practitioner may not furnish any item or 

service that would otherwise be covered by Medicare (except for 

emergency or urgent care services) to any Medicare beneficiary except 

through a private contract that meets the requirements of this subpart.

    (c) The physician or practitioner is not subject to the requirement 

to submit a claim for items or services furnished to a Medicare 

beneficiary, as specified in Sec. 424.5(a)(6) of this chapter, except 

as provided in Sec. 405.440.

    (d) The physician or practitioner is prohibited from submitting a 

claim to Medicare for items or services furnished to a Medicare 

beneficiary except as provided in Sec. 405.440.

    (e) In the case of a physician, he or she is not subject to the 

limiting charge provisions of Sec. 414.48 of this chapter, except for 

services provided under Sec. 405.440.

    (f) The physician or practitioner is not subject to the prohibition-

on-reassignment provisions of Sec. 414.80 of this chapter, except for 

services provided under Sec. 405.440.

    (g) In the case of a practitioner, he or she is not prohibited from 

billing or collecting amounts from beneficiaries (as provided in 42 

U.S.C. 1395u(b)(18)(B)).

    (h) The death of a beneficiary who has entered into a private 

contract (or whose legal representative has done so) does not invoke 

Sec. 424.62 or Sec. 424.64 of this chapter with respect to the 

physician or practitioner with whom the



[[Page 104]]



beneficiary (or legal representative) has privately contracted.

    (i) The physician or practitioner who has not been excluded under 

sections 1128, 1156, or 1892 of the Social Security Act may order, 

certify the need for, or refer a beneficiary for Medicare-covered items 

and services, provided the physician or practitioner is not paid, 

directly or indirectly, for such services (except as provided in Sec. 

405.440).

    (j) The physician or practitioner who is excluded under sections 

1128, 1156, or 1892 of the Social Security Act may not order, prescribe, 

or certify the need for Medicare-covered items and services except as 

provided in Sec. 1001.1901 of this title, and must otherwise comply 

with the terms of the exclusion in accordance with Sec. 1001.1901 

effective with the date of the exclusion.