What does it mean for a dentist to opt out of Medicare?

Opting out means signing an affidavit under 42 CFR 405.420 that states the dentist will furnish services to Medicare beneficiaries only through private contracts for a two-year opt-out period, will not submit any claim to Medicare for those services, and understands the beneficiary will not be reimbursed either. It is a formal, renewable status, not an informal decision to stop billing Medicare.

Can a Medicare patient still see an opted-out dentist?

Yes, but only under a private contract that meets the requirements of 42 CFR 405.415. The patient pays the dentist directly, at whatever rate the contract states, with no Medicare fee limit. The contract must be signed before the service is furnished and kept on file for the full opt-out period.

Can a patient submit their own claim to Medicare for an opted-out dentist's work?

No. Under 42 CFR 405.405, services furnished under a valid private contract are not covered services under Medicare, and no Medicare payment will be made for them, directly or indirectly. That bars reimbursement to the dentist and to the patient. A patient cannot file a CMS-1490S for this work and expect payment.

Do Medigap or other supplemental plans pay when Medicare does not?

Generally no. The private contract itself must disclose this in writing. Medigap plans do not make payments for items and services that Medicare does not pay for, and other supplemental plans may elect not to either. A beneficiary signing a private contract is agreeing to absorb the full cost, with no secondary-payer fallback assumed.

How long does an opt-out period last, and does it renew automatically?

An opt-out period is two years, beginning on the date the affidavit meeting 42 CFR 405.420 is signed. If the dentist takes no action at the end of the period, the opt-out renews automatically for another two years. Ending it requires an affirmative step, not silence.

Is there an exception for emergency or urgent dental care?

Yes. A beneficiary cannot be required to sign a private contract for emergency or urgent care. If an opted-out dentist furnishes emergency or urgent services without a private contract in place, the standard Medicare billing and payment rules apply to that encounter instead of the opt-out rules.

What happens if the affidavit or private contract does not meet the requirements?

Under 42 CFR 405.405, both the private contract and the opt-out status are null and void if the dentist fails to properly opt out or fails to stay in compliance with the subpart during the opt-out period. A defective contract does not just get corrected later. It can unwind the opt-out status itself for that period.

If You Opted Out of Medicare, What Can Your Medicare Patients Actually Do? The Private Contract Rules, Read Straight.

A dentist opts out of Medicare, tells the front desk to stop billing it, and assumes that is the whole transaction. It is not. Opting out is a status defined in federal regulation, at 42 CFR 405.400 through 405.455, and it comes with an affidavit, a contract template, and one rule that surprises almost every practice that has not read it: once you are properly opted out, the patient cannot get paid either, even if they try to file it themselves.

What does opting out of Medicare actually require?

Opting out is not a billing preference. It is a signed affidavit meeting 42 CFR 405.420, filed with the Medicare Administrative Contractor, stating the dentist’s name, address, NPI, and a binding commitment: services to Medicare beneficiaries will be furnished only through private contracts for the opt-out period, no claim will be submitted to Medicare for that work, and the dentist understands no Medicare payment will be received for it. The opt-out period runs two years from the date the affidavit is signed, and if the dentist does nothing at the end of it, the period renews automatically. Letting the fee schedule lapse informally is not the same thing as this affidavit, and it does not carry the same legal effect.

What must a private contract with a Medicare patient say?

The required disclosures

Under 42 CFR 405.415, the contract must state that the beneficiary agrees not to submit a claim to Medicare or ask the dentist to submit one, that Medicare payment will not be made for the services either way, that Medicare fee limits do not apply to what the dentist may charge, and that Medigap plans do not, and other supplemental plans may elect not to, pay for items Medicare does not cover. The contract must be signed before the service is furnished and kept on file, with original signatures, for the entire opt-out period.

Source: 42 CFR 405.415

Every one of those disclosures exists to remove ambiguity later. A patient who signs this contract cannot credibly claim they did not know Medicare would not pay. That is the point of writing it into the contract text rather than leaving it as a verbal explanation at the front desk.

Can the patient just file the claim themselves and get reimbursed?

This is the part practices get wrong most often. Under 42 CFR 405.405, services furnished under a private contract that meets the subpart’s requirements “are not covered services under Medicare, and no Medicare payment will be made for such services either directly or indirectly.” Directly means the dentist cannot bill Medicare. Indirectly means the patient cannot either, including through the CMS-1490S self-filing form that exists for other unassigned or non-participating scenarios. The door is closed on both sides, not just the provider side. A front desk that tells a Medicare patient “you can always file it yourself if you want reimbursement” is giving advice the regulation directly contradicts.

Does anything fall outside the opt-out, even for an opted-out dentist?

Yes, and it matters for triage. A Medicare beneficiary cannot be required to sign a private contract to receive emergency or urgent care. If an opted-out dentist treats a beneficiary under those circumstances without a contract in place, that specific encounter falls under ordinary Medicare rules rather than the opt-out rules. The distinction is not a loophole to lean on routinely. It exists for genuine urgent situations, and a practice that treats every visit as urgent to avoid the contract requirement is misreading the exception’s scope.

What breaks a valid opt-out, and what does that cost?

The regulation is unforgiving on defects. Under 42 CFR 405.405, both the private contract and the opt-out status itself “are null and void if the physician or practitioner fails to properly opt-out” or fails to remain in compliance with the subpart during the opt-out period. That is not a warning letter and a chance to fix the paperwork later. A defective affidavit or a private contract missing one of the required disclosures can unwind the opt-out status retroactively for that period, which reopens the question of what was actually billed, to whom, and under what authority.

Requirement	Governing section	What it fixes
Opt-out affidavit	42 CFR 405.420	Name, NPI, commitment not to bill Medicare, two-year term
Opt-out period length	42 CFR 405.400, 405.410	Two years from affidavit signature, auto-renews
Private contract terms	42 CFR 405.415	No Medicare claim, no fee limit, Medigap gap disclosed
No indirect payment	42 CFR 405.405	Patient cannot self-file for reimbursement either
Emergency exception	42 CFR 405.405	Urgent/emergency care falls under standard Medicare rules
Defect consequence	42 CFR 405.405	Contract and opt-out status void if requirements unmet

Why do so many opted-out arrangements drift out of compliance over time?

The affidavit and the first batch of contracts usually get done carefully, often with a consultant or an association template, at the moment the dentist decides to opt out. What drifts is everything after. A new associate joins the practice under a different enrollment status and the front desk applies the same private-contract script to that dentist’s patients without checking whether that dentist is actually opted out too. A returning patient signs a new private contract at a follow-up visit using a stale template that predates a regulatory update. The two-year renewal passes silently, which is fine under the auto-renewal rule, but nobody re-verifies that the contract language on file still matches current requirements. None of this looks like a decision. It looks like nothing happening, which is exactly how a compliant arrangement quietly stops being one.

What should a practice with opted-out dentists actually check?

Pull the affidavit on file and confirm it still names the correct NPI and was signed within the current two-year window. Pull a sample of private contracts signed in the last quarter and check each one against the five required disclosures in 405.415, not just the payment amount. Confirm the front desk script does not tell patients they can file their own claim afterward, since that instruction contradicts 405.405 outright. None of this changes how the practice bills. It changes whether the paperwork behind an opt-out decision would survive being read closely, by CMS or by a patient’s own lawyer.

Where this comes from

This piece draws on 42 CFR 405.400 through 405.455 (definitions, general rules, effects of opting out, affidavit requirements, and private contract requirements for physicians and practitioners under Medicare Part B), read directly from the current Code of Federal Regulations via Cornell Law School’s Legal Information Institute. If your practice runs both Medicare-enrolled and opted-out providers, the audit that finds where this distinction gets blurred in your own billing is a fifteen-minute conversation, not a project. Start it with the free ClaimRail audit.