Skip to main content

Direct Primary Care

Considerations for opting out of Medicare as a direct care physician

iStock 518338152

The structure of a direct primary care (DPC) practice relies on patient membership fees rather than insurance reimbursement. Many DPC physicians set up categories of fees that are based on the patient’s age, including those patients over age 65. Some DPC physicians may opt to accept Medicare reimbursement for those patients, but some choose to opt out. There are a number of considerations to think about when deciding whether to opt out of Medicare as a DPC physician.

The first consideration is that the Medicare opt-out is for a two-year period. After the two years, the DPC physician has the option to opt back in. This means that once the DPC physician opts out of Medicare, “they cannot submit claims to Medicare for any of their patients for a two-year period.”

Additionally, for the patients’ consideration, any outside services referred to by the DPC physician would still be covered by Medicare for those patients who are eligible for that coverage. For example, if a patient needs laboratory services that are not part of the DPC membership fee, Medicare would cover those costs, “provided the physician is not paid, directly or indirectly, for such services (except for emergency and urgent care services).”

DPC physicians who opt out of Medicare should ensure their patients are aware of their status. There may be complications for patients who have also secured a Medicare Advantage plan, which are “generally written to cover things that Medicare does not cover.” Physicians and patients must sign an agreement stating that, given the physician’s opt out status, none of the DPC services can be submitted to Medicare.

A DPC physician who decides to opt out of Medicare, “must file an affidavit that meets the necessary criteria and is received by the MAC (Medicare administrative contractors) at least 30 days before the first day of the next calendar quarter. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to Medicare as if they had never opted out.”