I have a Medicare Advantage plan. Can it pay for a doctor who opted out of Medicare?

Health insuranceWho paysChecked Nov 7, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-07 · Source: Medicare.gov · Does your provider accept Medicare as full payment? · Using a provider that "opts-out" of Medicare View original ↗

In short

Medicare won't pay a doctor who opted out, except in an emergency.
Your plan can't pay that doctor for basic care.
It must pay for emergency or urgent care there.

What this means

Some doctors opt out of Medicare. Medicare won't pay for items or services from a provider that opts out, except in emergencies [1]. Providers opt out for a minimum of 2 years [1].

Federal rules say a Medicare Advantage plan may not pay for basic benefits from a doctor who has filed an opt-out affidavit [2]. The plan must pay for emergency or urgently needed services from such a doctor who has not signed a private contract with you [3]. The plan may pay for services that are supplemental benefits [4].

If you choose an opt-out doctor, you may need to pay upfront under a private contract. Medicare won't pay for any service from that doctor, even a covered one [5]. You may want to call your State Health Insurance Assistance Program before you sign [6].

Your next step

Ask the doctor's office whether it has opted out of Medicare [1]. Before you sign a private contract, call your State Health Insurance Assistance Program [6]. The sources give no deadline.

Check it yourself

Use the Medicare.gov tool to find providers that opted out. Ask your plan which supplemental benefits it may pay for with this doctor [4]. Your plan's own list of supplemental benefits is not in these sources — "Don't know yet".

Where this comes from (6)

[1] Medicare.gov · Does your provider accept Medicare as full payment? · Using a provider that "opts-out" of Medicare · checked 2026-11-07
Medicare won’t pay for items or services you get from provider that opts out, except in emergencies. Providers opt out for a minimum of 2 years.
[2] eCFR · 42 CFR 422.220 · § 422.220(a) · checked 2026-11-07
an MA organization may not pay, directly or indirectly, on any basis, for basic benefits furnished to a Medicare enrollee by a physician
[3] eCFR · 42 CFR 422.220 · § 422.220(b) · checked 2026-11-07
An MA organization must pay for emergency or urgently needed services furnished by a physician or practitioner described in paragraph (a) of this section who has not signed a private contract with the beneficiary.
[4] eCFR · 42 CFR 422.220 · § 422.220(c) · checked 2026-11-07
An MA organization may make payment to a physician or practitioner described in paragraph (a) of this section for services that are not basic benefits but are provided to a beneficiary as a supplemental benefit
[5] Medicare.gov · Does your provider accept Medicare as full payment? · Private contracts with doctors or providers who opt out · checked 2026-11-07
If you choose to get services from an opt-out doctor or provider you may need to pay upfront, or set up a payment plan with the provider through a private contract. Medicare won’t pay for any service you get from this doctor, even if it’s a Medicare-covered service.
[6] Medicare.gov · Does your provider accept Medicare as full payment? · checked 2026-11-07
You may want to contact your State Health Insurance Assistance Program (SHIP) for help before signing a private contract with any doctor or other health care provider.

How we found this

We matched your question to 6 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-07.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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