Medicare Opt-Out for Physicians Practicing in Multiple States

Medicare Opt-Out for Physicians Practicing in Multiple States

Medicare Opt-Out for Physicians Practicing in Multiple States

If you’re a physician practicing across state lines—through telemedicine, locum tenens, or multi-location clinics—you may wonder about Medicare opt-out rules. Two common questions are:

1. Are you required to opt out if you practice in multiple states?

2. Does opting out in one state automatically apply everywhere?

Here’s the plain answer based on CMS guidelines.

1. Is opt-out required?No. Opting out of Medicare is voluntary. You are not forced to opt out simply because you practice in multiple states. You can remain:

• A participating provider, accepting Medicare’s allowed amount as full payment.

• A non-participating provider, billing up to 115% of the non-par fee schedule.

• An opted-out provider, entering private contracts and billing patients directly, with no Medicare reimbursement.

2. Nationwide effect of opt-outIf you choose to opt out, it is nationwide. You cannot bill Medicare for any patient anywhere in the U.S. for the duration of the opt-out (2 years, auto-renewable unless you opt back in).

3. Filing requirements

• You submit a separate opt-out affidavit to each Medicare Administrative Contractor (MAC) covering your practice locations.

• Many MACs cover multiple states, but if your practice spans multiple MACs, you must file with each one.

• Filing with one MAC does not automatically opt you out in other jurisdictions.

4. Risks of incomplete filingIf you fail to file with all relevant MACs, your opt-out may be incomplete, and you could accidentally bill Medicare, resulting in denied claims or compliance issues.

5. How to opt out

1. Complete the standard opt-out affidavit.

2. Submit to each relevant MAC at least 30 days before the effective date (first day of a quarter).

3. Use a private contract for each Medicare patient encounter.

Key Takeaways

• Opt-out is voluntary but nationwide once effective.

• Filing is per MAC, not per state—verify which MACs cover your practice locations.

• Consult your MAC or a healthcare attorney for personalized guidance.

References

• CMS Medicare Opt-Out Fact Sheet (ICN 903182)

• CMS Private Contracting/Opt-Out Page

• CMS MAC Contacts & Jurisdictions

• AMA Toolkit on Medicare Opt-Out

This information is for general guidance and not legal advice. Consult your healthcare attorney for legal advice.