• As of January 1, 2024, MFTs and counselors are eligible to participate as Medicare providers. This means these clinicians (and social workers and psychologists) must decide now about whether to enroll in Medicare. If you choose not to, there are still actions you should take.

 TELEHEALTH COVERAGE:

• Telehealth for psychotherapy (CPT codes 90785 – 90853) is now a permanently covered service for any site in the U.S. no matter where the client is at the time of the telehealth service, including their home. Audio-only (phone) sessions are also covered.
• An in-person visit is  required within six months prior to initiating telehealth services, and again annually afterwards,  HOWEVER, THIS REQUIREMENT HAS BEEN WAIVED UNTIL JANUARY 1, 2027.  It is possible that Congress will permanently waive this requirement before that time, or allow exceptions, but we’ll have to wait and see.

TELEHEALTH CODING

• For MEDICARE TELEHEALTH CLAIMS, Medicare has directed clinicians to use Place of Service (POS) code 10, even if the client was not at their home.  This is because POS telehealth code 02 will be paid by Medicare at an incorrectly reduced “facility rate”  (citation here).
• Modifier 95 should be used for video sessions, while modifier 93 should be used for phone sessions.

INTERSTATE THERAPY:

It was confirmed that you can provide services to clients located in another state at the time of the session.  However, you must be licensed in that other state, and you must enroll in the Medicare MAC in each state where you are located (not where the client is located).

RATES

While there are fee schedules posted on the Medicare websites, IT IS IMPORTANT TO NOTE THAT THE FEES THERE ARE NOT WHAT MFTS AND COUNSELORS WILL BE PAID (more about this later).  Also remember, rates depend on where you are located, and what service you are providing.

So, to view Medicare rates for your area and the service you are providing, you would:

• Go to the Physician Fee Schedule Rate search (click here)
• Click on “Non-QPP Rates”
• Under “Type of Information” click on “Pricing Information.”
• Under “HCPCS Criteria,” click on “Range of Codes” then type in 90791 to 90837 (or whatever CPT codes you want to check)
• Ignore “Modifiers”
• Under “MAC Option,” click on “Specific Locality” on the drop down menu.  Then start to enter the name of your city or state or county and choose the best option that comes up.
• Click on “Search fees,” and then scroll down.
• Look for the non-facility rate for each CPT code. If there are two rows listed for the same code, look for the code on the line that does NOT have a little hashtag next to it in the first column.
• BUT DON’T STOP THERE — THAT ISN’T THE RATE YOU’LL BE PAID, unless you are a psychologist!  MFTS and counselors will be paid 75% of the posted rate.  Psychologists will receive 100% of the amount listed.  My citation:  The Medicare’s own “Medicare & Mental Health” (citation here).”
• For a deeper dive in understanding Medicare reimbursement rates, click here to purchase Medicare expert Susan Frager’s guide

PROVIDER ENROLLMENT:

• If you want to work with Medicare, you can apply through the Medicare online PECOs system (click here) or with paper CMS-855I forms downloaded from your regional Medicare Administrative Contractor (MAC) website. To find your MAC website, click here, then do an online search for your MAC.
• Check out this helpful Medicare FAQ document — click here.
• You may have heard about a Medicare provider option called “non-par,” or “non-participating.” According to my sources, MFTs, counselors, social workers, and psychologists cannot be non-par.
• Here is a list of Medicare MACs and enrollment websites and phone numbers: click here
• Here is an email address that you can send questions to: Medicareproviderenrollment@cms.hhs.gov
• Here is a Medicare decision tree that I put together: click here
• There is a lot to say about enrolling, and — as I said — I’m not a Medicare expert. Also, Medicare isn’t easy, and there are a lot of ways to make mistakes.  So, my advice is to get help enrolling, or just get help deciding whether or not to enroll.  Contact Medicare expert Susan Frager, owner of www.psychbillingcoach.com for individual consultation on either of these subjects.
• Keep in mind that Medicare does audit provider charts, asking for your notes and treatment plans to support your billing. They may ask for money back if your documentation is not excellent.  So, it is essential to learn NOW what Medicare expects in progress notes and treatment plans, especially for telehealth sessions.  Prevent income loss — take my pre-recorded documentation webinars “What Should be In Your Charts” and “How to Write a 10-Minute Treatment Plan” — both are available here

OPTING-OUT

If you decide not to work with Medicare, it is strongly recommended that ALL therapists “opt-out” now.  Why?  Because you can’t collect money from Medicare clients on a self-pay basis if you don’t. If you don’t opt-out, Medicare could ask you to refund these clients.  While you may not have Medicare clients now, in the future a private client might become eligible for Medicare, either due to age or disability, or you might have a new client with Medicare.  Then you’ll wish you had taken care of this earlier.  This is where Medicare is different from private insurance.

Medicare opt-outs by healthcare providers last for a minimum of 2 years and automatically renew. You can only change your mind and terminate the opt out early if it is your very first time opting out, and you cancel within 90 days of the effective date.  Otherwise, you must stay opted out for the full 2-year term

But what do you need to do to opt-out?

• Download the Opt-Out Affidavit from your regional MAC website.  You may want to call your MAC to confirm where to send this form, but for a list of Medicare MACs and enrollment websites and phone numbers, click here .
• Important:  Are you a LPC or LPCC?  Opt-out affidavits submitted by LPCs/LPCCs have been rejected by Medicare, stating that these licenses cannot opt-out because they are “not eligible for Medicare.”  According to the California Assn of Marriage and Family Therapists (CAMFT), LPCs/LPCCs should submit/re-submit the opt-out forms and list “Mental Health Counselor” as their specialty type, as this is the umbrella they fall under.
• Answer every question on the form.  If the form asks for “Eligible Practitioner’s Wishes to Order & Refer?” check “no”.  Put N/A if they ask for a Medicare ID number or PTAN, unless you are a current Medicare provider.
• Date the opt-out form with today’s date.  This will be considered your opt-out date.
• BE SURE TO GIVE YOUR FULL MIDDLE NAME, even if it isn’t on your license.  Affdavits are often rejected without this.
• After filing this Affidavit with Medicare, download the Medicare Private Contract from your Medicare MAC website, and have each of your private Medicare clients sign this, notifying them that Medicare will not reimburse them.  There is no need to have a legal representative or witness signature in most cases.
•  You must opt-out in the Medicare MAC that has jurisdiction in each state where you are located; you should not need to do this in each state where your clients are located.  However, if you see clients in other states, you might want to reach out to the MAC in those states to confirm that no opt-out is needed there.
• Once you opt out, this will be in place for two years. It will automatically renew, but you will be notified at the two-year mark, in case you want to change your mind.
• IMPORTANT CONSIDERATIONS BEFORE OPTING OUT:  
  • BE SURE TO REACH OUT TO ALL INSURANCE PLANS YOU WORK WITH. Some plans require network providers to provide services to their Medicare members, or at least not to opt-out of Medicare.  More than one therapist has shared they were terminated from an insurance panel when she opted out of Medicare.  I do not know which plans might take this action.  I have been told that Kaiser requires Medicare participation from eligible network providers, and will terminate your contract if you Opt Out.  Also be sure that any platforms you belong to (Grow Therapy, Alma, Rula, Headway, etc) will still accept you if you opt-out.  Grow Therapy has told us at the time of this article they do no accept opted-out providers, and I believe Rula doesn’t, either.  See my article on this issue — click here 
  • When a provider opts out, they cannot bill Medicare in any practice setting or care delivery context for those 2 years.  That is, you can’t accept Medicare at one location and not do so at another.
  • Keep in mind that opting-out can make it difficult to find a job at an agency or group practice that accepts Medicare.   Since the Opt-Out is good for two years, this can be a 2 year obstacle.
• For more information about opting out and the Private Contract, Susan Frager has published a wonderful Opt-Out Guide with the answers to all your questions (plus ones you didn’t think to ask) which includes links to all Opt Out Affadavit Forms and Private Contracts — click here.

CALLING MEDICARE —  A TIP

I tried calling my local Medicare MAC (Noridian) with a question about rates.  In the automated system, I asked for “enrollment” and was asked for my NPI.  When it didn’t recognize my NPI, it wouldn’t proceed.  At that point I said, “Customer Service,” “Customer Representative,” and I was able to talk to a live person.