Engaging With Medicare Advantage Plans

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What are the advantages of becoming a Medicare advantage provider?

Over 52 percent of Medicare beneficiaries are enrolled in Medicare Advantage plans so it is important for practitioners to engage health plans to enroll in their systems to treat beneficiaries in addition to those enrolled in Traditional Medicare.

Does a provider have to reapply if they are already in a Medicare Advantage network?

Yes.

Will providers need to apply to become providers for both traditional Medicare as well as each Medicare Advantage (MA) plan and Medigap policies?

Yes.

Will providers need to be credentialed with each MA health plan?

Yes.

If I am part of a current health insurance provider panel or network will I automatically be eligible to treat Medicare beneficiaries?

It is unclear until we receive more clarity. If as a provider you are currently serving on a health plan panel, you may be automatically enrolled to participate in the plan to serve Medicare beneficiaries. But you should check with health plan representatives.

Will Medicare Advantage beneficiaries need a referral to receive mental health services from counselors and MFTs?

Under MA plans, it is likely that beneficiaries will need to a referral but it may differ from individual health plan to health plan.

Are Associates or Interns under supervision eligible to participate in Medicare?

No.

What does provider assignment mean?

Medicare decides how much to pay providers for covered services. Most providers accept the Medicare-approved amount for services Medicare covers, even if it’s less than they usually charge. If the provider agrees to the approved amount, he or she is accepting assignment.

A provider who accepts assignment agrees to charge you no more than the amount Medicare has approved for that service. A provider who participates in Medicare but doesn’t accept assignment can potentially charge you up to 15 percent more than the Medicare-approved amount.

Do providers have to “opt out?” What happens if they don’t opt out. For instance, if they are not interested in working with Medicare clients do a provider have to do anything?

MFTs and MHCs have two choices — They can enroll as a Medicare provider or opt out.

Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment.
Opt-out providers who do not accept Medicare at all must sign an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services to Medicare clients but must follow certain rules to do so.
- Medicare will not pay for care that a beneficiary receives from an opt-out provider (except in emergencies). A beneficiary is responsible for the entire cost of the care that an MHC or MFT provides.
- The MHC and MFT must give the client a private contract describing their charges and confirming that the client understands they are responsible for the full cost of services and that Medicare will not reimburse.
- Opt-out providers do not bill Medicare for services a client receives.
- Many psychiatrists have opted out of Medicare.

The 2024 Medicare Physician Fee Schedule Proposed Rule was silent on opt-out procedures and NBCC and the Medicare Coalition will comment on this omission (more information on opting out could be included in the Final 2024 Fee Schedule Rule).

How does a provider opt out of Medicare? If I opt out of Medicare, is that choice final and permanent and cannot be reversed later?

If you want to Opt Out of Medicare, Medicare Administrative Contractors (MACs) are now accepting opt-out affidavits. Be aware, each MAC has its own opt-out affidavit form. The forms cannot be faxed or emailed. They must be physically mailed to the appropriate MAC via CERTIFIED mail. If you are seeing any Medicare beneficiaries, and you decide to Opt-Out of becoming a Medicare provider, you are also required to enter into a private contract with your Medicare-eligible patient(s).

Medicare opt-out affidavits are good for two years and renew automatically every two years, unless the practitioner notifies the Medicare Administrative Contractor that they wish to enroll as a Medicare provider.

As part of their standard procedures, MACs send out renewal notifications 90 days prior to the opt- out affidavit’s renewal date. Practitioners who do not want their opt-out to automatically renew at the end of a 2 year opt-out period, may cancel the renewal by notifying all contractors (MACS) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.

Can a practitioner apply as a Medicare Provider and get accepted, but change one’s mind?

Medicare providers may decide they no longer want to provide services to Medicare eligible patients, but in order to no longer be a participating provider, the provider would have to notify their MAC and take the appropriate steps to opt out as a Medicare provider. Those steps include filling out and mailing an opt-out affidavit to the appropriate MAC or MACs and entering into private pay contracts with Medicare eligible patients. Affidavits and private pay contract templates can be accessed through the MACs’ websites.

I was told that if providers ‘opt out’ of Medicare, they will no longer be eligible for enrollment as ‘in network’ with the insurance company, in other words, they will be unpaneled?

A provider who has opted out of Medicare will still be able to participate as a provider with all health plans that are not Medicare managed care plans.

Do providers have to reapply if they are already in a Medicare Advantage network?

If you are already enrolled in a network that offers Medicare Advantage services, contact the health plan/network to request that the terms of your contract be expanded to include Medicare services.