Medicare opt-out practice advertising rules

A cash-pay practice that sees people over 65 gets the same question on the phone each week: do you take Medicare? The honest answer depends on a status the practice chose with Medicare, not on a preference. A physician who has formally opted out, a physician who is enrolled but nonparticipating, and a clinician who never enrolled are in three different legal positions, and each one changes what the website, the ads and the booking flow can say to a person with Medicare.

This guide covers the advertising side of Medicare opt-out: how to describe your status, how to handle urgent requests, what to say about Medicare Advantage and supplemental plans, and how cost estimates fit in. The private contract terms and the federal alert on membership fees for covered services are covered in our concierge medicine marketing guide. Membership fees, HSAs and direct primary care are in our direct primary care marketing guide. Publishing prices is in advertising cash prices, and estimates for self-pay patients are in our good faith estimate guide. Offers and gifts to people with Medicare are in marketing to Medicare patients. For patients with private plans when you are out of network, see our guide to advertising an out-of-network practice.

This is general information, not legal or billing advice. Sources cited were checked on October 30, 2026: 42 CFR 405.400 through 405.455 (Medicare private contracts and opt-out), 42 CFR 414.48 (limiting charge), 42 U.S.C. 1395w-4(g)(4) (claim submission), 45 CFR 149.610 (good faith estimates for uninsured or self-pay individuals), 15 U.S.C. 45, and the CMS Opt Out Affidavits dataset on data.cms.gov. Medicare rules change, and state law can add its own requirements. Have a health care attorney and your billing advisor confirm your status before you publish anything about Medicare.

Three statuses that sound alike

Patients and staff use “we do not take Medicare” for all three of these. The rules treat them very differently.

Participating. 42 CFR 405.400 defines a participating physician as one who has signed an agreement to participate in Part B. The practice bills Medicare under that agreement.
Enrolled but nonparticipating. The practice is still in Medicare and still submits claims. Under 42 CFR 414.48, a nonparticipating supplier who does not accept assignment may charge up to the limiting charge, which for services paid under the physician fee schedule is 115 percent of the fee schedule amount for nonparticipating suppliers.
Opted out. The physician or practitioner has filed an affidavit under 42 CFR 405.420 and treats people with Medicare only under private contracts that meet 42 CFR 405.415. Under 42 CFR 405.425, no Medicare claim is submitted and no Medicare payment is made, apart from the emergency and urgent care rules described below, and the limiting charge does not apply.

A fourth group is the clinician who never enrolled in Medicare and never opted out. That is not a fourth way to run a cash practice for people with Medicare. Under 42 U.S.C. 1395w-4(g)(4), a physician or supplier who furnishes a service paid under Part B has to complete and submit the claim on the beneficiary’s behalf and may not charge for doing so. 42 CFR 405.425(c) is the provision that lifts that requirement for clinicians who have properly opted out. If your practice treats people with Medicare for covered services and has done neither, talk to a health care attorney before you advertise anything to them.

Who can opt out

The opt-out rules apply only to the clinicians listed in 42 CFR 405.400. Physicians, for this purpose, are doctors of medicine, osteopathy, dental surgery or dental medicine, podiatric medicine and optometry. Practitioners are physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical psychologists, clinical social workers, marriage and family therapists, mental health counselors, and registered dietitians or nutrition professionals.

Chiropractors and physical therapists are not on that list. A chiropractic or physical therapy practice that sees people with Medicare cannot use this opt-out route to run as a cash practice for them, so marketing that copies the wording of an opted-out medical practice can be wrong for those offices. Ask counsel what applies to your license.

Opt-out is also personal to each clinician. The affidavit is signed by the physician or practitioner, and 42 CFR 405.410(b) requires it to go to each Medicare Administrative Contractor the clinician would otherwise bill. In a group where one clinician has opted out and another has not, a sentence such as “our practice has opted out of Medicare” can be wrong for half the team.

How opt-out works, in the parts that touch marketing

Timing. Under 42 CFR 405.410(c) and (d), a nonparticipating physician or practitioner may opt out at any time, and a participating physician may opt out at the start of a calendar quarter with the affidavit filed at least 30 days before that quarter begins. Do not announce a cash-pay launch to Medicare patients before the effective date.
Length. 42 CFR 405.400 sets a 2-year opt-out period and each following 2-year period, unless the clinician cancels. Under 42 CFR 405.445(a), cancellation needs written notice to each contractor at least 30 days before the current period ends.
Each patient, each period. 42 CFR 405.415(o) requires a private contract for each 2-year period, and 405.415(h) requires the contract to state the expected or known start and end dates of the current period.
Medicare Advantage. Under 42 CFR 405.425(a) and 405.455, Medicare Advantage plans may not pay an opted-out clinician for covered services either, apart from the emergency and urgent care rules.
Orders and referrals. Under 42 CFR 405.425(i), an opted-out clinician who is not excluded and whose enrollment is not revoked may still order, certify, prescribe or refer for Medicare-covered items and services, as long as the clinician is not paid for them by Medicare.

The penalties for getting the mechanics wrong fall on the practice and on patients. Under 42 CFR 405.430 and 405.435, a failed or broken opt-out can make the private contracts void, require claims to Medicare for covered services, bring back the limiting charge, and in some cases leave neither the clinician nor the patient with Medicare payment for the rest of the period. A marketing page cannot fix that, but it can avoid making promises that only hold if the paperwork is right.

What the website should say

The goal is a statement a person with Medicare can understand before they book, in the same words your private contract uses. Keep it on the page where people decide: the fees page, the new patient page and the booking page, not only in a footer.

Use:

“Dr. [Name] has opted out of Medicare. If you have Medicare, you can still see Dr. [Name], but only under a private contract you sign before care starts. Medicare will not pay for those visits, and you agree not to send a claim to Medicare.”
“Our fees are set by us, not by Medicare. Medicare limits on what a physician may charge do not apply to these visits.”
“Medicare Advantage plans and Medigap plans will not pay for these visits. Other supplemental plans may also decline. Check with your plan before you book.”
“You have the right to get Medicare-covered care from clinicians who have not opted out. If you would like to use your Medicare benefits, we are glad to help you find a clinician who accepts Medicare.”
“Our current opt-out period runs from [date] to [date].”

Avoid:

“Submit your receipt to Medicare for reimbursement” or “you may be reimbursed by Medicare”. Under 42 CFR 405.405(e), services under a valid private contract are not covered, and no Medicare payment is made directly or indirectly.
“Your Medigap plan may cover this.” 42 CFR 405.415(i) requires the contract to say that Medigap plans do not pay for these services.
“We do not take Medicare” with no explanation, when the real status is nonparticipating or never enrolled. A short line that hides a different status can mislead under 15 U.S.C. 45, and it sets up the wrong conversation at the front desk.
“Medicare patients have no other choice” or any line that pressures a patient. 405.415(g) requires the contract to state that the patient is not compelled to contract privately.
Statements that one clinician’s status applies to the whole practice when it does not.

15 U.S.C. 45 makes deceptive acts or practices in commerce unlawful, and the FTC looks at the net impression an ad leaves. A Medicare page that is correct in the fine print but suggests reimbursement in the headline can still mislead.

Urgent requests and online booking

Opt-out has a timing rule that cash-pay websites can miss. 42 CFR 405.415(k) says a private contract may not be entered into while the patient needs emergency or urgent care. 42 CFR 405.400 defines urgent care services as services that have to be furnished within 12 hours to avoid the likely onset of an emergency medical condition.

Under 42 CFR 405.440, an opted-out clinician may still treat a person with Medicare who needs emergency or urgent care and has not signed a private contract. In that case the clinician must submit a claim to Medicare and may collect no more than the limiting charge (for a physician) or the deductible and coinsurance (for a practitioner). Care for a patient who signed a contract before the condition began is furnished under that contract.

For marketing, that means:

Do not run “same-day” or “urgent visit” ads that send a person with Medicare to a contract signing page. A patient who needs care within hours is not in a position to sign one, and the rule says they may not be asked to.
Put a plain emergency line on the booking page: “If this is an emergency, call 911. If you are in crisis, call or text 988.”
Give the front desk and any online chat a script for a new caller with Medicare who describes an urgent problem: no contract, no cash price, follow the urgent care billing rules or direct them to the right setting.
Make the contract part of a scheduled new patient step, sent ahead of the first visit, not a click-through at checkout.

Cost estimates for patients with Medicare

Our good faith estimate guide covers the federal estimate rule for uninsured and self-pay patients. Opted-out practices ask whether it applies to their Medicare patients. The definition in 45 CFR 149.610(a)(2) has two parts. Part (A) covers a person with no benefits for the item or service under a group health plan, health insurance coverage, a Federal health care program or a federal employee plan. Part (B) covers a person who has benefits under a group health plan, health insurance coverage or a federal employee plan but does not seek to have a claim submitted. Part (B) does not list Federal health care programs.

Read literally, a person with Medicare who chooses to see an opted-out clinician does not fit either part neatly, so the federal estimate rule may not reach that visit. We could not confirm a CMS statement on this exact situation when we checked. Ask your attorney before you decide, and if a patient also has other coverage, the answer can change.

Whatever the answer, a written price before care starts is good practice for a cash practice, and the private contract already requires the patient to accept full responsibility for payment under 42 CFR 405.415(c). A clear fee schedule on the site, matched by the contract, is the simplest way to keep the two in line. Pricing claims are covered in advertising cash prices.

Ads, listings and directories

Search ads. If an ad targets terms such as “Medicare” or “doctor who takes Medicare”, the landing page must answer the question in its first screen. Sending people who want to use their Medicare benefits to a cash-only page without saying so wastes their time and your budget.
Business profile. If your listing has an insurance or payment field, make it match your status. Do not list Medicare as accepted when the clinician has opted out.
Directories and plan lists. Under 42 CFR 405.455(a), Medicare Advantage organizations must keep information on clinicians who have opted out. If a plan directory still lists an opted-out clinician, ask the plan to correct it rather than advertising around it.
Public data. CMS publishes an Opt Out Affidavits dataset on data.cms.gov with the clinician’s NPI, specialty, address and effective dates. The latest release listed in the CMS catalog when we checked was dated September 1, 2026. Patients and plans can look you up, so your site should match it.

Membership and direct pay models

Opt-out and membership are separate decisions. A practice can charge a membership fee without opting out, and an opted-out clinician can bill per visit with no membership. The two meet when a membership practice wants to sign up people with Medicare. Our concierge guide covers the federal alert on fees for covered services and the full list of private contract terms, and our direct primary care guide covers HSA wording, which does not apply to people entitled to Medicare. If the membership renews automatically, see membership auto-renewal rules.

Where practices go wrong

The website says “opted out” before the effective date, or after the clinician has cancelled opt-out and returned to billing Medicare.
One clinician opts out and the practice page describes everyone that way.
A chiropractic or physical therapy office copies an opted-out physician’s “we do not take Medicare” page, although its clinicians cannot opt out under this subpart.
The page says Medicare Advantage plans are fine because “we are out of network”. Under 42 CFR 405.455(b), those plans may not pay opted-out clinicians for covered services.
Same-day booking for new patients with Medicare goes straight to a contract and a card payment, with no route for urgent needs.
Receipts are labeled as “superbills” for Medicare, which invites patients to file claims the contract says they will not file.
Staff in the call center say “you can try sending it to Medicare”.

Claims to leave out

These lines show up on cash-pay sites and are hard to support under 15 U.S.C. 45, which bars deceptive acts or practices in commerce:

“Medicare patients save money with us.” A person with Medicare pays your full fee and gets no Medicare payment for the visit. Any savings claim needs a reasonable basis before it runs.
“Better care than Medicare doctors.” A comparison with other clinicians needs evidence you can show, and the private contract itself has to tell patients they may see clinicians who accept Medicare.
“Medicare approved.” An opted-out clinician is not billing Medicare, and the phrase suggests coverage.
“No paperwork.” The private contract is required paperwork for each patient with Medicare, for each 2-year period.

An illustration

This example is invented to show the steps, not a real client. [Practice name] is a two-physician internal medicine office moving to cash pay. One physician will opt out at the start of the next calendar quarter. The other will stay enrolled for now. The practice drafts two short Medicare notices, one per physician, and puts them on each physician’s profile page and on the fees page. The booking form asks whether the patient has Medicare, and if the answer is yes for the opted-out physician, it schedules a new patient call where staff send the private contract to read ahead. Search ads for “Medicare doctor” are paused, and the business profile payment field is updated on the effective date, not before. The front desk script for an urgent call from a new patient with Medicare is printed next to the phone, with 911 and 988 at the top.

Checklist before you publish

Confirm each clinician’s status in writing: participating, nonparticipating, opted out with dates, or not eligible to opt out.
Match the wording on the site to the private contract and to the CMS opt-out data.
Name Medicare Advantage, Medigap and other supplemental plans correctly.
Put the Medicare notice on the fees, new patient and booking pages.
Keep urgent requests away from contract signing, and show 911 and 988.
Remove any reimbursement or “submit to Medicare” wording.
Set a reminder to review the page before each 2-year period ends and whenever a clinician’s status changes.
Have counsel decide how cost estimates apply to patients with Medicare.

How we help

We build websites, local search, Google Ads and lead generation and AI front desk tools for independent practices and health businesses. For a cash-pay or opted-out practice, that means fees and Medicare pages written in plain words and matched to your contract, booking flows that ask about Medicare before a card is taken, ad campaigns that avoid sending people who want to use their benefits to the wrong page, and front desk scripts for urgent calls. Our tools are built with HIPAA in mind. We confirm in writing what a BAA covers before any patient information flows through a tool, and if it is not covered, we do not route patient information through it. We are not a healthcare provider and we do not give legal or billing advice. For the wider rules, see our healthcare marketing rules hub.

Is “we do not take Medicare” the same as opting out?

No. Opting out is a formal status under 42 CFR 405.410 with an affidavit filed with each Medicare Administrative Contractor and a private contract with each patient who has Medicare. A nonparticipating clinician is still enrolled and still submits claims. A clinician who never enrolled and never opted out is still subject to the claim submission rule in 42 U.S.C. 1395w-4(g)(4) for covered services.

Can a patient with Medicare get reimbursed for visits with an opted-out physician?

Under 42 CFR 405.405(e), services under a valid private contract are not covered and no Medicare payment is made directly or indirectly. The patient also agrees in the contract not to submit a claim. The exception is emergency or urgent care for a patient with no private contract, which follows 42 CFR 405.440.

Do Medicare Advantage plans pay opted-out clinicians?

Not for covered services. 42 CFR 405.425(a) and 405.455(b) bar payment by Medicare Advantage plans, apart from emergency or urgent care for patients who have not signed a private contract.

Can a chiropractor opt out of Medicare?

Chiropractors are not among the physicians or practitioners listed in 42 CFR 405.400, so the opt-out subpart does not cover them. Ask a health care attorney what applies to your practice.

How long does opt-out last?

42 CFR 405.400 sets 2-year periods that continue unless the clinician cancels. Under 42 CFR 405.445(a), cancellation requires written notice to each contractor at least 30 days before the current period ends.

Does the good faith estimate rule apply to opted-out Medicare visits?

The definition of uninsured or self-pay individual in 45 CFR 149.610(a)(2) does not fit a person with Medicare who chooses to see an opted-out clinician neatly, and we could not confirm CMS guidance on that exact case. Ask your attorney, and give a written price before care either way.

Medicare opt-out and cash-pay practices: what your website and ads can say