Jane M. Orient, M.D.
Executive Director - Association of American Physicians and Surgeons
1601 N. Tucson Blvd. #9
Tucson, AZ 85716
Dear Dr. Orient
Thank you for your inquiry regarding whether a beneficiary who is enrolled in a Medicare health maintenance organization (HMO) can privately contract with an ophthalmologist. Please excuse the delay in my reply.
Where the Medicare HMO is a risk plan that contracts with Medicare, beneficiaries who enroll in the plan give up their right to coverage under Medicare, except for those services covered by the HMO. If the beneficiary goes outside the plan and acquires services from a physician who is not in the plan's network and the plan will not otherwise cover the services of the physician, then the services are not covered by Medicare and the physician is free to charge the beneficiary. No private contract is needed for the physician to charge the beneficiary for the services that are not covered by Medicare in this case and the physician does not need to sign an affidavit opting out of Medicare to charge the beneficiary for this service without regard to the Medicare limiting charge. If the beneficiary subsequently submits the claim to the HMO and the HMO decides to cover the service, then the physician must refund any amount collected in excess of the Medicare limiting charge for the covered physician service.
I trust this information is helpful to you.
Health Insurance Specialist
Center for Health Plans and Providers