A newsletter for Highmark Blue Shield of Northeastern New York (Highmark BSNENY) network providers
Issue 4, April 2023
Federal regulations prohibit Medicare Advantage (MA) organizations, including Highmark Blue Shield of Northeastern New York (BSNENY) , from paying for services rendered by providers who have chosen to opt out of the Medicare program, except in limited circumstances.
An MA organization may contract only with providers who are eligible for participation in the Medicare program and who have not opted out of Medicare (See Social Security Act § 42 CFR § 422.220). Opting out is not the same as “non-participating.” Providers who opt out of Medicare cannot participate in our MA Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) networks.
Highmark BSNENY will not cover any services provided by providers on or after the effective opt-out date… unless the service was eligible for payment as an emergency or urgently needed under applicable Medicare standards.
The Centers for Medicare and Medicaid Services (CMS) regulations for opt-out physicians or practitioners also require a “private contract” between the Medicare beneficiary and the provider who opted out of Medicare. The private contract must include language such as, but not limited to, agreement that the Medicare beneficiary gives up Medicare payment — including payment from MA plans — for services furnished by the opt-out provider, as well as to pay the provider for services directly.
Providers may cancel their opt-out by submitting written notice to the Medicare Administrative Contractor no later than 30 days before the end of the current two-year opt-out period. If providers want early termination of their opt-out status, there are specific Medicare requirements that must be met in a timely manner and providers must not have previously opted out.
Physicians and practitioners must follow CMS rules regarding opting out of Medicare. The requirements and possible exceptions are outlined in the CMS Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services. The manual is accessible here 
.
If your status with Medicare changes, you must notify us promptly by calling 800-346-6262. More information for New York State providers is available from the local Medicare Administrative Contractor, National Government Services website .
