# 42 C.F.R. § 405.425 (2026): Effects of opting-out of Medicare > Federal · Regulations · In force URL: https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_425 ## Section - **Citation:** 42 C.F.R. § 405.425 (2026) - **Heading:** Effects of opting-out of Medicare - **Jurisdiction:** Federal - **Kind:** Regulations - **Status:** In force - **Text as of:** August 14, 2026 - **Source:** Compiled text - **Location:** Title 42 CFR: Public Health / Chapter IV: CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES / Part 405: FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED / Subpart D: Private Contracts / § 405.425: § 405.425 Effects of opting-out of Medicare. ## Text If a physician or practitioner opts-out of Medicare in accordance with this subpart, the following results obtain during the opt-out period: (a) Except as provided in § 405.440, no payment may be made directly by Medicare or by any Medicare Advantage plan to the physician or practitioner or to any entity to which the physician or practitioner reassigns his right to receive payment for services. (b) The physician or practitioner may not furnish any item or service that would otherwise be covered by Medicare (except for emergency or urgent care services) to any Medicare beneficiary except through a private contract that meets the requirements of this subpart. (c) The physician or practitioner is not subject to the requirement to submit a claim for items or services furnished to a Medicare beneficiary, as specified in § 424.5(a)(6) of this chapter, except as provided in § 405.440. (d) The physician or practitioner is prohibited from submitting a claim to Medicare for items or services furnished to a Medicare beneficiary except as provided in § 405.440. (e) In the case of a physician, he or she is not subject to the limiting charge provisions of § 414.48 of this chapter, except for services provided under § 405.440. (f) The physician or practitioner is not subject to the prohibition-on-reassignment provisions of § 414.80 of this chapter, except for services provided under § 405.440. (g) In the case of a practitioner, he or she is not prohibited from billing or collecting amounts from beneficiaries (as provided in 42 U.S.C. 1395u(b)(18)(B)). (h) The death of a beneficiary who has entered into a private contract (or whose legal representative has done so) does not invoke § 424.62 or § 424.64 of this chapter with respect to the physician or practitioner with whom the beneficiary (or legal representative) has privately contracted. prohibited from billing or collecting amounts from beneficiaries (as provided in 42 U.S.C. 1395u(b)(18)(B)). (h) The death of a beneficiary who has entered into a private contract (or whose legal representative has done so) does not invoke § 424.62 or § 424.64 of this chapter with respect to the physician or practitioner with whom the beneficiary (or legal representative) has privately contracted. (i) The physician or practitioner who has not been excluded under sections 1128, 1156 or 1892 of the Act and whose Medicare enrollment is not revoked under § 424.535 of this chapter may order, certify the need for, prescribe, or refer a beneficiary for Medicare-covered items, services, and drugs, provided the physician or practitioner is not paid, directly or indirectly, for such services (except as provided in § 405.440). (j) The physician or practitioner who is excluded under sections 1128, 1156 or 1892 of the Act or whose Medicare enrollment is revoked under § 424.535 of this chapter may not order, prescribe or certify the need for Medicare-covered items, services, and drugs except, with respect to exclusions, as provided in § 1001.1901 of this title, and must otherwise comply with the terms of any exclusion in accordance with § 1001.1901 of this title effective with the date of the exclusion. [63 FR 58901, Nov. 2, 1998, as amended at 79 FR 68001, Nov. 13, 2014; 80 FR 71370, Nov. 16, 2015; 84 FR 47852, Sept. 10, 2019] ## Nearby sections - [42 C.F.R. § 405.400 (2026) § 405.400 Definitions.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_400.md) - [42 C.F.R. § 405.405 (2026) § 405.405 General rules.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_405.md) - [42 C.F.R. § 405.410 (2026) § 405.410 Conditions for properly opting-out of Medicare.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_410.md) - [42 C.F.R. § 405.415 (2026) § 405.415 Requirements of the private contract.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_415.md) - [42 C.F.R. § 405.420 (2026) § 405.420 Requirements of the opt-out affidavit.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_420.md) - [42 C.F.R. § 405.425 (2026) § 405.425 Effects of opting-out of Medicare.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_425.md) - [42 C.F.R. § 405.430 (2026) § 405.430 Failure to properly opt-out.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_430.md) - [42 C.F.R. § 405.435 (2026) § 405.435 Failure to maintain opt-out.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_435.md) - [42 C.F.R. § 405.440 (2026) § 405.440 Emergency and urgent care services.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_440.md) - [42 C.F.R. § 405.445 (2026) § 405.445 Cancellation of opt-out and early termination of opt-out.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_445.md) - [42 C.F.R. § 405.450 (2026) § 405.450 Appeals.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_450.md) - [42 C.F.R. § 405.455 (2026) § 405.455 Application to Medicare Advantage contracts.](https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_455.md) --- Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/CFR_T42_P405_S405_425. 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