Information and Helpful Links for Therapists Who Want to Opt Out of Medicare
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Greetings Colleagues,
For those of you that follow my blogs, or those clinical peers I am honored to work with in a coaching, consulting, or supervision capacity, welcome! You will notice that this blog is starting off a bit differently than my other blogs with an important disclaimer to read before you proceed any further. I share this because, as a therapist who is private pay, I am not an expert in the world of insurance, and I am not an expert in Medicare. I am sharing the following information as a support, to save you hours of time, and so that you have links and helpful information available to support the good work you are doing in the world helping hurting people heal.
Note that the information provided below is focused on California mental health therapists. However, I do provide a couple of links with helpful information for non-California therapists as well. My hope in compiling all of this is to take some of the stress off of your shoulders as we are all busy bees!
But first the legal “stuff”…
The content provided on this therapy blog is for informational purposes only and is not intended as professional or legal advice. As a mental health therapist coaching other therapists, I am not responsible for the use or misuse of any information presented on this platform. The information is not a substitute for professional judgment or your own research.
Therapists reading this blog are encouraged to conduct their own research and exercise their own professional discretion before applying any ideas or suggestions outlined on this blog.
Therapists who are insurance based should contact the insurance plans that they work with to understand what each insurance plan policies are with network providers and opting out of Medicare as some insurance plans may require that therapists who are network providers provide services to their Medicare members. You may risk being terminated from your insurance panel/plan if you opt out of Medicare and they do not allow this. Each insurance based therapist must do their own research to be fully informed and proceed with caution.
While I strive to provide accurate and up-to-date information, I make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability, or availability of the information contained on this blog. Any reliance you place on such information is strictly at your own risk.
In no event will I be liable for any loss or damage, including without limitation, indirect or consequential loss or damage, or any loss or damage whatsoever arising from the use of this blog.
By continuing to read and engage with this content, you acknowledge and agree to these terms. If you require professional advice tailored to your specific situation, it is recommended that you consult with a qualified professional to assist you, or contact the various agencies in your state or jurisdiction.
OK, now that we’ve got that out of the way, I have outlined the following information that goes into effect on January 1, 2024, when MFTs and counselors are eligible to participate as Medicare providers. This means mental health clinicians, including psychologists and social workers, will need to make a decision about whether to enroll in Medicare or to Opt Out no later than 1/1/24.
Please note that there are important steps that are highly recommended to take now if you decide to opt OUT of medicare. By choosing not to go through the steps of opting out of medicare (if that is your choice), there are significant risks to be aware of.
What are the risks of not following through on the recommended steps of opting out of medicare if my choice to opt out?
You cannot collect money for therapy sessions from Medicare clients as a private pay/self pay basis if you do not first opt out from Medicare (steps to Opt Out are listed below).
If you choose not to mail in the opt out affidavit form, and you are accepting private pay (out of pocket) fees from self pay clients who are enrolled in Medicare, then Medicare may ask you to refund all of the money the client has paid to you for their therapy sessions.
This may be considered fraud (asking medicare clients to pay out of pocket/private pay if you have not opted out, and also made them aware of this through an opt out private pay client contract, more on the contract below).
Even if you do not have medicare clients currently, one of your clients may become eligible for medicare in 2024, or you may start to work with a new medicare client in 2024. If you have not followed the Opt out steps with your MAC, then you cannot charge them as a private pay client.
Once you opt out of medicare, there is a time period for this to be processed, so don’t wait until the last minute and then scramble.
Remember, Medicare is different in this way from private insurance.
Important consideration: Therapists who are insurance based should contact the insurance plans that they work with to understand what each insurance plan policies are with network providers and opting out of Medicare as some insurance plans may require that therapists who are network providers provide services to their Medicare members. You may risk being terminated from your insurance panel/plan if you opt out of Medicare and they do not allow this. Each insurance based therapist must do their own research to be fully informed and proceed with caution.
Medicare Opt Out Steps to Take
Locate the MAC Medicare Administrative Contractor(s) in your state (see below link)
Download, print out the Opt out affidavit form from your state/jurisdiction MAC
Fill out the Opt out form from your Mac, physically sign and date the form
Keep a copy of the form for your files
Locate the specific mailing address for your MAC/State/Jurisdiction (for example, northern and southern California have different mailing addresses for Noridian which is our MAC, see below for those addresses for California)
Mail your signed and dated Opt out affidavit to your MAC via certified mail (certified mail is strongly recommended)
Follow up in 30 days to ensure that your MAC received your form and is processing this
Create (or download from your MAC) the opt out private pay client contract (see below for more information). You can create your own, but it is recommended to use your MACs opt out private pay client contract form on your letter head to ensure you are verbalizing in your form the specific language that they want you to use. For California therapists, I have provided the link to the Opt out private pay client contract form below
Add a statement to your intake forms (I have provided mine below as a support). This statement does NOT replace opting out, or the Opt Out Private Pay Client Contract form.
Make sure you alert all current or new clients of this, and have them sign your Opt Out Private Pay Client Contract if they are on medicare, or if they will become eligible for medicare in 2024.
Do all of this prior to January 1, 2024
Remember that the Medicare Opt Out designation lasts for 2 years from the date you opted out, then automatically renews at the 2 year mark. You will be alerted prior to the opt out renewal at the end of 2 years in case you would like to change your designation and opt in. Otherwise it will auto renew to opt out. Make sure all of your information, email, etc. is current, and I would suggest adding a reminder to your calendar in 2 years time in order to ensure that you remain opted out (if that is your choice to opt out).
Medicare Opt Out Information
Forms Links and Article Links
Locate your MAC (Medicare Administrative Contractors) in your state/jurisdiction (for California, it is Noridian):
Medicare Administrative Contractors list by state (jurisdiction):
https://www.cms.gov/files/document/macs-state03282023pdf.pdfMedicare Administrative Contractor (MAC) map: https://www.cms.gov/files/document/ab-jurisdiction-map03282023pdf.pdf
Once you’ve located your MAC in your state/jurisdiction, go to their website and follow the steps to opt out, or to opt in if that is your choice. Even if you are not a California therapist, scroll through this article as there will be other helpful information for you.
Steps to opt OUT of Medicare for California therapists:
Locate your MAC. Here is a link for the list of all MACs per state/jurisdiction::
https://www.cms.gov/files/document/macs-state03282023pdf.pdf
Noridian is the MAC (Medicare Administrative Contractor) for California, here is their website: https://med.noridianmedicare.com/
Link to the Opt OUT Noridian affidavit form for California (if you are choosing to Opt OUT): https://med.noridianmedicare.com/documents/10534/3228833/Opt-Out+Affidavit
NOTE: You must download, print out, fill in, physically sign and date, and send to the Noridian address via certified mail. You cannot fill out the form on their website. Again, the above link is for California therapists.
NOTE: your decision to opt out will be made public on the CMS Opt-Out Dataset.
Link for Noridian address for California (scroll down on the form on their website to California):
https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/downloads/contact_list.pdf
Noridian’s mailing addresses:
Northern California Provider Enrollment mailing address (all other counties):
Provider Enrollment
P.O. Box 6774
Fargo, ND 58108-6774Southern California Provider Enrollment mailing address (counties: Ventura, Los Angeles, Orange, Imperial, San Diego, Santa Barbara and San Luis Obispo):
Provider Enrollment
P.O. Box 6775
Fargo, ND 58108-6775
NOTE: If you are a California therapist and you have clients across the state of California (both northern and southern California) you may need to send affidavits to all of the PO Box addresses for Noridian if you provide therapy (meaning you are located sometimes in So Cal and sometimes in No Cal and provide therapy from your So Cal and No Cal locations). CALL NORIDIAN DIRECTLY TO CONFIRM.
Noridian Private Pay Opt Out “Medical Services”
Information and Contract Form for California:
Noridian’s Private Pay Client Contract form link: https://med.noridianmedicare.com/documents/10525/2052366/Opt-Out+Private+Contract
Link for further information on how to structure your private pay client contract per Medicare rules if you choose to opt out and create your own private pay form. Note: you will need to copy and paste this PDF link into your browser:
https://theinsurancemaze.com/wp-content/uploads/2023/03/Enrollment-Guide_-Chapter-9-Private-Contracting-Opt-Out-Novitas-indepth-explanation-of-optout-rules.pdfFurther helpful information Mari: In addition to the Noridian’s medicare private pay client form (which I will use and create on my practice letter head) that I will have client's sign, I will also be adding this statement to my intake forms. I am sharing the following content in case this is helpful:
Note: This intake form statement does NOT replace the Medicare opt out steps or opt out private pay client contract forms/steps that are required by medicare:
Are you enrolled with medicare? Yes____ No____
If you are enrolled in Medicare, kindly note that Mari A. Lee, LMFT, operating/DBA under Growth Counseling Services, is not enrolled with Medicare, does not participate in Medicare, or accept Medicare. Mari A. Lee and Growth Counseling Services is not affiliated with Medicare panels and has chosen to opt out of Medicare. Mari A. Lee DBA Growth Counseling Services operates on a fee-for-service basis, all clients are private pay which requires payment directly from clients for therapy services. As a result, you will not be able to seek reimbursement for therapy sessions with Mari A. Lee DBA Growth Counseling Services through Medicare if you are enrolled with Medicare. Please sign here to indicate that you understand and agree to this:
Client signature: _________________________________________
Important Articles on this Topic
I hope that each of you will take the time to carefully read the following important articles, and do the research you need to do in order to be fully informed as no blog or professional can provide every bit of information, and, information may change or update in the future. Thus, going straight to the government website pages and sources is wise:
Centers for Medicare and Medicaid Services:
https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/chain-ownership-system-pecos/manage-your-enrollment#opt-outMFT and Medicare FAQ:
CAMFT Medicare Opt Out/In Information:
https://www.camft.org/Members-Only/Medicare-Corner/Medicare-Opt-Out-Information
Informative Articles on this Topic
As an additional support, here are two other informative articles that you may want to read on this topic. Barbara Griswold has many years of expertise in the insurance world, and has also provided excellent information in these articles: https://theinsurancemaze.com/optout/#:~:text=If%20you%20are%20a%20LCSW,Medicare%20client%20in%20your%20practice.
Update
January 18, 2024 update: I sent my opt out affidavit via registered mail early December 2023 and received an email on January 18th, 2024 confirming my opt out request from Noridian (again, I am located in California). There was a 3 page letter attached to the email that states in part, “Noridian approved your Medicare opt-out affidavit” along with other information. The email in part stated the following,
“Dear Valued Customer,
We are pleased to inform you that your Opt Out Affidavit is finalized, and the notification letter which contains important effective date information is attached.
Any other questions can be directed to our Provider Contact Center at the numbers provided below.
Thank you,
NORIDIAN HEALTHCARE SOLUTIONS LLC
So, keep your eye out for an email that should arrive confirming your opt out (if you choose to opt out) within 6-8 weeks, at least by my timeline, though I am sure it varies from state to state, and county to county. My suggestion is to add a reminder to your calendar 8 weeks from your mail date and if you have not received confirmation via mail or email, perhaps contact the medicare administrative contractor MAC in your area to check the status of your request.
In closing, I hope that this information will help support you as you move through these important steps. If you have questions beyond what I have covered here, please contact your MAC directly.
It can be a time consuming “fluster cluck” of a process trying to figure all of this out, locate forms, and information. If this was helpful, please introduce yourself and comment below.
You can learn more about my coaching work and what other colleagues have shared about my support here. You are welcome to schedule a coaching or consulting session here.
Kindly and in support,
Mari