PRIA, Government Policy, Made Personal

Summary

People who get Medicare can choose any qualified doctor, clinic, or hospital that agrees to treat them. A doctor or other provider may make a private contract with a Medicare patient to provide and be paid for a service outside of Medicare only if the provider will not submit a Medicare claim and will not get any Medicare payments for that service. Before care, the private contract must be written and signed by the patient, must not be used in an emergency, and must clearly say the patient agrees not to seek Medicare payment, will pay for the service themselves, understands Medicare limits on charges do not apply (including the limit in section 1395w–4(g)), and that Medigap (section 1395ss) or other supplemental plans may not pay. The provider must also file a signed affidavit with the Secretary of Health and Human Services saying they will not bill Medicare for items or services covered by the contract for a 2-year period, and must send a copy to the Secretary within 10 days after the first such contract. If a provider knowingly bills Medicare during that 2-year period, the private-contract rules stop and no Medicare payments will be made for services from that date until the period ends. The affidavit renews every 2 years unless the provider tells the Secretary at least 30 days before the period ends that they do not want to continue. Starting by February 1, 2016, HHS must post yearly lists about opt-out providers (how many, specialties, locations, timing, and how many billed for emergency or urgent care). A "Medicare beneficiary" is someone entitled to Part A or enrolled in Part B; an "opt-out" provider is one with the affidavit on file.

Title 42, §1395a

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Basic freedom of choice

Any individual entitled to insurance benefits under this subchapter may obtain health services from any institution, agency, or person qualified to participate under this subchapter if such institution, agency, or person undertakes to provide him such services.

(b)Use of private contracts by medicare beneficiaries

(1)In general

Subject to the provisions of this subsection, nothing in this subchapter shall prohibit a physician or practitioner from entering into a private contract with a medicare beneficiary for any item or service—

(A)for which no claim for payment is to be submitted under this subchapter, and

(B)for which the physician or practitioner receives—

(i)no reimbursement under this subchapter directly or on a capitated basis, and

(ii)receives no amount for such item or service from an organization which receives reimbursement for such item or service under this subchapter directly or on a capitated basis.

(2)Beneficiary protections

(A)In general

Paragraph (1) shall not apply to any contract unless—

(i)the contract is in writing and is signed by the medicare beneficiary before any item or service is provided pursuant to the contract;

(ii)the contract contains the items described in subparagraph (B); and

(iii)the contract is not entered into at a time when the medicare beneficiary is facing an emergency or urgent health care situation.

(B)Items required to be included in contract

Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the medicare beneficiary that by signing such contract the beneficiary—

(i)agrees not to submit a claim (or to request that the physician or practitioner submit a claim) under this subchapter for such items or services even if such items or services are otherwise covered by this subchapter;

(ii)agrees to be responsible, whether through insurance or otherwise, for payment of such items or services and understands that no reimbursement will be provided under this subchapter for such items or services;

(iii)acknowledges that no limits under this subchapter (including the limits under section 1395w–4(g) of this title) apply to amounts that may be charged for such items or services;

(iv)acknowledges that Medigap plans under section 1395ss of this title do not, and other supplemental insurance plans may elect not to, make payments for such items and services because payment is not made under this subchapter; and

(v)acknowledges that the medicare beneficiary has the right to have such items or services provided by other physicians or practitioners for whom payment would be made under this subchapter.

Such contract shall also clearly indicate whether the physician or practitioner is excluded from participation under the medicare program under section 1320a–7 of this title.

(3)Physician or practitioner requirements

(A)In general

Paragraph (1) shall not apply to any contract entered into by a physician or practitioner unless an affidavit described in subparagraph (B) is in effect during the period any item or service is to be provided pursuant to the contract.

(B)Affidavit

An affidavit is described in this subparagraph if—

(i)the affidavit identifies the physician or practitioner and is in writing and is signed by the physician or practitioner;

(ii)the affidavit provides that the physician or practitioner will not submit any claim under this subchapter for any item or service provided to any medicare beneficiary (and will not receive any reimbursement or amount described in paragraph (1)(B) for any such item or service) during the applicable 2-year period (as defined in subparagraph (D)); and

(iii)a copy of the affidavit is filed with the Secretary no later than 10 days after the first contract to which such affidavit applies is entered into.

(C)Enforcement

If a physician or practitioner signing an affidavit under subparagraph (B) knowingly and willfully submits a claim under this subchapter for any item or service provided during the applicable 2-year period (or receives any reimbursement or amount described in paragraph (1)(B) for any such item or service) with respect to such affidavit—

(i)this subsection shall not apply with respect to any items and services provided by the physician or practitioner pursuant to any contract on and after the date of such submission and before the end of such period; and

(ii)no payment shall be made under this subchapter for any item or service furnished by the physician or practitioner during the period described in clause (i) (and no reimbursement or payment of any amount described in paragraph (1)(B) shall be made for any such item or service).

(D)Applicable 2-year periods for effectiveness of affidavits

In this subsection, the term “applicable 2-year period” means, with respect to an affidavit of a physician or practitioner under subparagraph (B), the 2-year period beginning on the date the affidavit is signed and includes each subsequent 2-year period unless the physician or practitioner involved provides notice to the Secretary (in a form and manner specified by the Secretary), not later than 30 days before the end of the previous 2-year period, that the physician or practitioner does not want to extend the application of the affidavit for such subsequent 2-year period.

(4)Limitation on actual charge and claim submission requirement not applicable

section 1395w–4(g) of this title shall not apply with respect to any item or service provided to a medicare beneficiary under a contract described in paragraph (1).

(5)Posting of information on opt-out physicians and practitioners

(A)In general

Beginning not later than February 1, 2016, the Secretary shall make publicly available through an appropriate publicly accessible website of the Department of Health and Human Services information on the number and characteristics of opt-out physicians and practitioners and shall update such information on such website not less often than annually.

(B)Information to be included

The information to be made available under subparagraph (A) shall include at least the following with respect to opt-out physicians and practitioners:

(i)Their number.

(ii)Their physician or professional specialty or other designation.

(iii)Their geographic distribution.

(iv)The timing of their becoming opt-out physicians and practitioners, relative, to the extent feasible, to when they first enrolled in the program under this subchapter and with respect to applicable 2-year periods.

(v)The proportion of such physicians and practitioners who billed for emergency or urgent care services.

(6)Definitions

In this subsection: (A) Medicare beneficiary

(B)Physician

The term “physician” has the meaning given such term by paragraphs (1), (2), (3), and (4) of section 1395x(r) of this title.

(C)Practitioner

The term “practitioner” has the meaning given such term by section 1395u(b)(18)(C) of this title.

(D)Opt-out physician or practitioner

The term “opt-out physician or practitioner” means a physician or practitioner who has in effect an affidavit under paragraph (3)(B).

Notes & Related Subsidiaries

Editorial Notes

Amendments

2015—Subsec. (b)(3)(B)(ii). Pub. L. 114–10, § 106(a)(1)(A)(i), substituted “during the applicable 2-year period (as defined in subparagraph (D))” for “during the 2-year period beginning on the date the affidavit is signed”. Subsec. (b)(3)(C). Pub. L. 114–10, § 106(a)(1)(A)(ii), substituted “during the applicable 2-year period” for “during the 2-year period described in subparagraph (B)(ii)” in introductory provisions. Subsec. (b)(3)(D). Pub. L. 114–10, § 106(a)(1)(A)(iii), added subpar. (D). Subsec. (b)(5). Pub. L. 114–10, § 106(a)(2)(C), added par. (5). Former par. (5) redesignated (6). Subsec. (b)(5)(D). Pub. L. 114–10, § 106(a)(2)(A), added subpar. (D). Subsec. (b)(6). Pub. L. 114–10, § 106(a)(2)(B), redesignated par. (5) as (6). 2003—Subsec. (b)(5)(B). Pub. L. 108–173 substituted “paragraphs (1), (2), (3), and (4) of section 1395x(r)” for “section 1395x(r)(1)”. 1997—Pub. L. 105–33 designated existing provisions as subsec. (a), inserted heading, and added subsec. (b).

Statutory Notes and Related Subsidiaries

Effective Date

of 2015 Amendment Pub. L. 114–10, title I, § 106(a)(1)(B), Apr. 16, 2015, 129 Stat. 138, provided that: “The

Amendments

made by subparagraph (A) [amending this section] shall apply to affidavits entered into on or after the date that is 60 days after the date of the enactment of this Act [Apr. 16, 2015].”

Effective Date

of 1997 Amendment Pub. L. 105–33, title IV, § 4507(c), Aug. 5, 1997, 111 Stat. 442, provided that: “The amendment made by subsection (a) [amending this section and section 1395y of this title] shall apply with respect to contracts entered into on and after January 1, 1998.” Updating the Welcome to Medicare Package Pub. L. 114–255, div. C, title XVII, § 17003, Dec. 13, 2016, 130 Stat. 1331, provided that: “(a) In General.—Not later than 12 months after the last day of the period for the request of information described in subsection (b), the Secretary of Health and Human Services shall, taking into consideration information collected pursuant to subsection (b), update the information included in the Welcome to Medicare package to include information, presented in a clear and simple manner, about options for receiving benefits under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), including through the original medicare fee-for-service program under parts A and B of such title (42 U.S.C. 1395c et seq., 42 U.S.C. 1395j et seq.), Medicare Advantage plans under part C of such title (42 U.S.C. 1395w–21 et seq.), and prescription drug plans under part D of such title (42 U.S.C. 1395w–101 et seq.)). The Secretary shall make subsequent updates to the information included in the Welcome to Medicare package as appropriate. “(b) Request for Information.—Not later than 6 months after the date of the enactment of this Act [Dec. 13, 2016], the Secretary of Health and Human Services shall request information, including recommendations, from stakeholders (including patient advocates, issuers, and employers) on information included in the Welcome to Medicare package, including pertinent data and information regarding enrollment and coverage for Medicare eligible individuals.” Report to Congress on Effect of Private Contracts Pub. L. 105–33, title IV, § 4507(b), Aug. 5, 1997, 111 Stat. 441, required a report to be submitted to Congress, no later than Oct. 1, 2001, on the effect on the program under title IV of Pub. L. 105–33 of certain private contracts.

§1395a Free Choice by Patient Guaranteed

Summary

Title 42, §1395a

Notes & Related Subsidiaries

Editorial Notes

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Amendments

Effective Date

Citations & Metadata