back to spring 2025 newsletter

In January 2024, the long-awaited admission of Marriage and Family Therapists into the Medicare system as Medicare providers finally went into effect. Fifteen months into this effective date, many MFTs are still deer-in-headlights, frozen-into-paralysis on how to really make an informed decision of whether to enroll, opt-out, or stay un-enrolled. There are a lot of sources online and as with many topics, so much misinformation is tangled in the mix. As both Barbara Griswold and Susan Frager point out, not taking any action or making uninformed hasty decisions can lead to significant financial and legal consequences, like having to refund payments or being sanctioned for billing errors.

Gia: Medicare can be intimidating and confusing, and it does have a bad rap of being full of red tape, paying on the lower end of the scale and requiring even more documentation than usual. MFTs are now eligible to be Medicare providers but deciding on whether one should enroll, or opt-out and or choose not to do anything is very confusing.

Barbara: I would say you have three choices when it comes to Medicare. Your first option is to  “enroll” as a Medicare provider.  This means you can serve the Medicare population and get reimbursed by Medicare. To enroll, you have to go through a very rigorous application process.

Your second option is to  “opt out,” wherein you are basically telling Medicare in a very formal way that you don’t want to work with them. And this is something I want to clarify -  unlike private insurance plans, if you don’t want to be involved withMedicare, you have to submit and sign a formal  “opt-out” affidavit. (link to Opt Out Affidavit  - https://med.noridianmedicare.com/documents/10525/2052366/Opt-Out+Affidavit.pdf)

The third option is you do nothing (we’ll talk more about this option later).

Gia: What are the ramifications of enrolling vs. opting out?

Barbara:  If you enroll with Medicare, you are able to provide services for the over-age-65 and disabled population, but you have to accept the Medicare discounted rate.   The good news is that Medicare publishes their rates so you can see how much they pay for your services in your city to help make this choice.  You can opt out but you might not realize that you just closed a door that really could be a significant source of income for you – Medicare clients..

Every potential client who walks in your door has to be asked if they have Medicare. If they do, and you are a Medicare provider, you must bill Medicare.  If you’re opted out, you have to make them sign a Medicare Private Pay Agreement that basically says “I know that Medicare is not going to cover this service but I still want to see you.”  (https://med.noridianmedicare.com/documents/10525/2052366/Opt-Out+Contract+Sample/5deeee5c-8e25-46a0-b90d-34ba5ef4fb2b)

It’s basically informing your client and getting their consent that they understand they could go see a Medicare provider but are choosing not to, and that they understand they will be paying out-of-pocket.

The signed Private Pay Agreement protects you if that client ever files a complaint, because you have proof that you informed the client that this is not going to be reimbursed by Medicare, and you informed them of the ability to go elsewhere.

Here’s where it gets complex: Medicare doesn’t want you to see Medicare clients in your private practice if you haven’t opted out, and haven’t gotten that Private Pay Agreement from your client.  But a lot of clinicians are choosing not to enroll, but also choosing not to opt out, because they're afraid the health plan might kick them off the provider panel. So they're weighing the danger and the risk, and doing nothing. They are just flying under the radar, by seeing private pay Medicare clients, and hoping that Medicare doesn't  find out.

Susan: If you are credentialed with, say Kaiser Medicare Advantage or one of the platforms like Rula or Grow, they may require you to NOT opt out. They may say “you don’t need to ENROLL as a provider in Original Medicare, but you CAN’T opt out because we want you to be able to see our Medicare Advantage clients.” In the many webinars and workshops I have given regarding enrolling or not as a Medicare provider, I often hear “ I feel stuck because my managed care contracts are saying I can't opt out.” And when you participate with  some managed care plans, you can't opt out. Or they work for other jobs where they can't opt out because “my job has to be able to bill Medicare for me.” https://psychbillingcoach.com/product/opting-out-of-medicare/

Gia: Can a MFT just do nothing, not enrolling and not opting-out?

Barbara: Here’s where it gets complex: Medicare doesn’t want you to see Medicare clients in your private practice if you haven’t opted out, and haven’t gotten that Private Pay Agreement from your client.  But a lot of clinicians are choosing not to enroll, but also choosing not to opt out, because they're afraid the health plan might kick them off the provider panel. So they're weighing the danger and the risk, and doing nothing. They are just flying under the radar, by seeing private pay Medicare clients, and hoping that Medicare doesn't  find out.

Susan: It is okay to stay unenrolled as long as you follow the rules and don’t see Medicare clients in your private practice. But if a therapist isn’t formally opted out and takes cash from a Medicare client, they're going to be made to give it to Medicare.

If you are not enrolled, you need to make sure that every client you see does not have Medicare. Even more than that, though, you should look at their insurance cards. I mean, I can't tell you how often a client isn’t clear. . They may say they have Aetna, but you could get their card and you see it says ‘Medicare Advantage.’ Just about all of the commercial insurance companies  offer Medicare Advantage plans. https://psychbillingcoach.com/i-dont-want-to-enroll-in-medicare/

Gia: What are the basic differences between Medicare and Medicare Advantage?

Susan: In this country, when you turn 65, you become eligible for Medicare. You get a choice - sign up for Original Medicare or you can choose to enroll in a Medicare program administered by a private health plan, such as United Healthcare Medicare Advantage, Humana Medicare Advantage, Anthem Medicare Advantage, Kaiser Medicare Advantage, etc.

Original Medicare provides the same benefits for everybody, which is a small deductible each year and then it’s. a 20% copayment. With Original Medicare, there's no such thing as verifying benefits for mental health because they're always the same. All you have to do is verify eligibility and you look at deductible status. Only about 48% of people with Medicare are enrolled in Original Medicare.

Meanwhile, Medicare Advantage is a hybrid, basically commercial insurance grafted onto Medicare and if your client has  a Medicare Advantage plan, you need to find that out because that means you bill the Advantage plan, not Original Medicare.

Gia: What are the basic factors to consider in making an informed decision on whether to become a Medicare provider?

Susan: I don't believe there's one right answer. I really don't. Because what kind of community do you practice in? Who are your clients? Are your clients seniors? Are they disabled?  And when we say disabled, we're not just talking about physically disabled, but mentally disabled too. We're talking about anybody who receives Social Security disability and gets Medicare through SSDI.

If these are your clients,  you kind of have no choice. If you don’t take Medicare, how are they going to be able to afford your services? 

Now if you work with kids, you might as well just opt out, right? Because most kids aren't going to have Medicare until they're old enough to age out into where they can get disability on their own. So as long as they're able to be carried under their parents’ policies until age 26, you're not going to have to worry about Medicare.

If you're in a really wealthy community, like parts of the Bay Area, you may have clients able and willing to pay your full fee on a cash basis. But in areas where clients depend on Medicare reimbursement, Medicare may actually pay comparably to managed care. Their reputation for being the lowest of the low isn’t always justified. The reimbursement for master-level clinicians in the Bay Area is $133.17 for a 90837. That may be comparable or even better than what would be paid by private plans like  Anthem, Blue Shield, or Cigna. So you should really consider your geographic location and the demographic you serve.

Barbara Griswold is a Licensed Marriage and Family Therapist who has been in private practice for the last 33 years and has parlayed her experience with numerous insurance providers into 20 years of consultancy and training other professionals. The author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should, now in its 10th edition, Barbara is a consultant to therapists nationwide with questions about insurance, progress notes, or practice building. For answers to your questions about Medicare and insurance, check out Barbara’s book and her other insurance courses at www.theinsurancemaze.com/store.

Susan Frager started as a clinician about three decades ago and eventually found herself learning the often-confusing procedures of private insurance and Medicare credentialing and billing. Although becoming a biller was not her intent, she found herself helping work colleagues obtain authorizations, navigate billing and keeping abreast of changes in the system. Today, Susan is a nationally recognized figure in the Medicare maze and walks people through the complex enrollment process.  For answers to your questions on Medicare enrollment, check out Susan’s website at www.psychbillingcoach.com to schedule a consultation.