Understanding Medicare Provider Enrollment or Opting Out for LMFTs, LPCs and Behavioral Health Providers: What you Need to Know
Now that Licensed Marriage and Family Therapists (LMFTs) and Licensed Professional Counselors (LPCs, also some LPCCs depending on state definition) can enroll with Medicare, we are seeing more questions about what it means to enroll or opt out with Medicare.
For the recently approved licensures, know this: You cannot do nothing.
Failing to enroll means you won't be able to see any Medicare clients or those on Medicare Advantage plans from other insurers - not even as Private Pay/Cash clients. So whether you’re an LMFT or LPC, or a previously approved LICSW or Psychologist, here’s what you need to know about the different types of provider relationships with Medicare:
Participating Providers
Participating providers accept Medicare and always take assignment, meaning they agree to accept Medicare’s approved amount as full payment for their services. Benefits include:
Streamlined Billing: Providers handle billing and Medicare pays them directly.
Cost to Clients: Clients pay 20% coinsurance for Medicare-covered services.
Assignment Requirement: Certain providers, such as clinical social workers, must always take assignment if they accept Medicare.
Non-Participating Providers
Non-participating providers accept Medicare but can choose whether to take assignment on a case-by-case basis. Key points include:
Flexible Billing: Providers can charge up to 15% more than Medicare’s approved amount (limiting charge).
Higher Client Costs: Clients may pay up to 35% of the approved amount (20% coinsurance + 15% limiting charge).
State Variations: Some states have lower limiting charges (e.g., New York at 5%).
Opt-Out Providers
Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the program. Important aspects are:
Full Responsibility: Clients are responsible for the entire cost of care, with no reimbursement from Medicare.
Private Contracts: Providers must give clients a contract detailing charges and confirming their understanding of the cost responsibilities.
Exclusions: Medicare won’t cover services from opt-out providers, except in emergencies.
Why This Matters
Understanding the type of relationship you have with Medicare can significantly impact what your client’s pay for services. Here’s how it breaks down:
Participating Providers: Simplifies the billing process and keeps client costs lower.
Non-Participating Providers: Offers flexibility in billing but may lead to higher out-of-pocket expenses for your clients.
Opt-Out Providers: Clients bear full costs, often with no supplemental insurance coverage.
Steps to Take
Get Enrolled with Medicare or Opt Out: You cannot do nothing. It is illegal to charge a Medicare client Private Pay rates if you are not Opted Out.
Understand Financial Implications: Know the costs associated with each type of provider relationship to avoid surprise bills for your clients.
Stay Informed: Keep up-to-date with any changes in Medicare policies that might affect your practice.
For behavioral health practice owners and providers, enrolling with Medicare and understanding these distinctions is essential for ensuring you can serve Medicare clients effectively. If you need assistance with the enrollment process or have questions about Medicare, BreezyBilling is here to help. Contact us today to discuss your needs and how we can support your practice.
We also offer Medicare Enrollment or Opting Out via our sister company, Phoenix Credentialing. Learn more about that at phoenixcredentialing.com/medicare.
Ensure you’re fully informed and ready to provide the best care for your Medicare clients by enrolling and understanding your options with Medicare!
