C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart D—Private Contracts

42 C.F.R. § 405.420

Requirements of the opt-out affidavit

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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 § 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 § 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-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 § 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 Advantage 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 § 405.440 apply if the physician furnishes such services.

[63 FR 58901, Nov. 2, 1998, as amended at 79 FR 68001, Nov. 13, 2014]
Notes of Decisions
Cited in 28 cases, 1981–2018 · leading case: Baptist Hosp. East, Et Al., Plaintiffs-appellants, v. Sec'y of Health & Human Servs., Defendant-appellee, 802 F.2d 860 (6th Cir. 1986).
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Baptist Hosp. East, Et Al., Plaintiffs-appellants, v. Sec'y of Health & Human Servs., Defendant-appellee, 802 F.2d 860 (6th Cir. 1986). · cites it 9× “They appeal a decision of the United States District Court for the Western District of Kentucky upholding 42 C.F.R. § 405.420 under which the Secretary of Health and Human Services denied their claims for reimbursement.”
St. James Hosp. v. Harris, 535 F. Supp. 751 (N.D. Ill. 1981). · cites it 4× “42 C.F.R. § 405.420 (g) is the regulation controlling the Hill-Burton issue, reimbursement of the claimed percentage of uncompensated care costs.”
Catholic Med. Ctr. v. New Hampshire-Vermont Hospitalization Serv., Inc., 707 F.2d 7 (1st Cir. 1983). · cites it 3× “42 C.F.R. § 405.420 (a) and (b). “The failure to collect charges for services rendered does not add to the cost of providing the services [inasmuch as] [s]uch costs have already been incurred in the production of the services.”
Johnson Cnty. Mem'l Hosp. v. Schweiker, 527 F. Supp. 1134 (S.D. Ind. 1981). · cites it 5× “” 42 CFR § 405.420 (b)(2). Charity care is viewed as a reduction in revenue.”
Indiana Hosp. Ass'n, Inc. v. Schweiker, 544 F. Supp. 1167 (S.D. Ind. 1982). · cites it 2× “42 C.F.R. § 405.420 (a). Since the exact amount of the bad debts incurred by Medicare patients in the foregoing areas is reimbursed, it is logical to deny reimbursement, either directly or as an item of overhead, of similar losses of revenue attributable to non-Medicare…”
Mem'l Hosp., Cross-Appellees v. Margaret M. Heckler, Sec'y, Dep't of Health & Human Servs., Cross-Appellant, 706 F.2d 1130 (11th Cir. 1983). “43658 (Oct 1, 1982), to be codified at 42 C.F.R. § 405.420 , provides: (b) Definitions.”
Alabama Hosp. Ass'n, a Corp. v. Rebecca Beasley, Individually, & in Her Capacity as Comm'r of the Alabama Medicaid Agency, 702 F.2d 955 (11th Cir. 1983). “See 42 C.F.R. §§ 405.420 , 405.451 (1979). In revising the statute Congress sought to move away from the inflationary Medicare reimbursement methodology.”
Iredell Mem'l Hosp., Inc. v. Schweiker, 535 F. Supp. 795 (W.D.N.C. 1982). · cites it 2× “Defendant contends that the uncompensated care required by Hill-Burton constitutes “charity” as it is defined in 42 C.F.R. § 405.420 (b)(2) (1980): “reductions in charges made by the provider of services because of the indigence or medical indigence of the patient”, and thus it…”
Forfar v. Walmart, 2018 COA 125 (Colo. Ct. App. 2018). “§ 1395u(b)(18)(B) (2012); 42 C.F.R. § 405.420 (2017);  to the extent that the providers’ private contracts with him provided otherwise, because those contracts did not comply with the disclosure requirements of Medicare, they are — as the trial court found — null and void, see…”
Dist. Hosp. Partners, L.P. v. Sebelius, 932 F. Supp. 2d 194 (D.D.C. 2013). “89 was originally codified in 1966 as 42 C.F.R. § 405.420 . Principles for Reimburseable Costs, 31 Fed.”
Med. Rehab. Servs., P.C. v. Shalala, 17 F.3d 828 (6th Cir. 1994). · cites it 4× “MRS then posted this loss in its Medicare cost reports as a bad debt and sought reimbursement under 42 C.F.R. § 405.420 . B. Bad debts are reductions in a provider’s revenue, not actual costs incurred in the delivery of medical services, and are not included as allowable costs…”
St. Francis Hosp. Ctr. v. Heckler, 714 F.2d 872 (7th Cir. 1983). · cites it 2× “42 C.F.R. § 405.420 (a). Since the exact amount of the bad debts incurred by Medicare patients in the foregoing areas is reimbursed, it is logical to deny reimbursement, either directly or as an item of overhead, of similar losses of revenue attributable to non-Medicare…”
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— 42 C.F.R. § 405.420(a) — 2 cases
Iredell Mem'l Hosp., Inc. v. Schweiker, 699 F.2d 196 (4th Cir. 1983).
Iredell Mem'l Hosp., Inc. v. Schweiker, 699 F.2d 196 (4th Cir. 1983).
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