What If I Receive Emergency or Urgently Needed Services from an Opt-Out Provider?Opt-out providers do not accept Medicare and have signed an agreement to be excluded from the Medicare program. Usually, this means that Original Medicare (or your Medicare Advantage Plan) will not pay for care that you receive from an opt-out provider, and that you will be responsible for the entire cost of your care. If you see an opt-out provider for non-emergency services, the provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of care.

However, there is an exception for emergency or urgently needed services. If you have Original Medicare and receive emergency or urgent care services from an opt-out provider, and you do not have a private contract with the provider, the opt-out provider has limits to what they can charge you. In this case, the opt-out provider may not charge you more than the Medicare limiting charge (up to 15% more than Medicare’s approved amount for the services received), and they must submit the claim for services provided to Medicare for you. Similarly, if you have a Medicare Advantage Plan, your plan must pay for emergency or urgently needed services that you receive from opt-out providers.

Note that once you no longer need emergency or urgent care, Medicare will not pay for follow-up care. If you are going to see the opt-out provider for further treatment, the provider must ask you to sign a private contract. You will responsible for the full out-of-pocket cost for the services you receive.

Read More: Does Medicare Cover Emergency Medical Services that I Receive in Another Country?
Learn About: How Can I Access Care If I Live in an Area Affected By a Disaster or Public Health Emergency?
Return to: Medicare In-Depth

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