clinical social work association

Medicare - Opting In or Out

Medicare Clarification – Required LCSW Opt In/Opt Out -- December, 2010

Medicare is a complex system which has caused confusion for many LCSWs.  Most LCSWs know that we must accept referrals if we sign up as a Medicare provider.  What has been less clear is that LCSWs must “opt out” of the Medicare system, or they will be considered available to receive Medicare patients and be violating Federal law by not accepting Medicare patients.  LCSWs are “eligible” to become Medicare providers but are in limbo until they “opt-in” by completing Medicare enrollment forms.  Information on how to opt-in or opt-out follows below.

 "Opting-Out” of Being a Medicare Provider

Once an LCSW becomes a Medicare provider, he or she may opt out of Medicare and privately contract with beneficiaries to provide services that would be covered by Medicare. The opt-out period is generally for two years. Opt-outs may be renewed for subsequent two-year periods. The provider must opt out of Medicare for ALL beneficiaries and services with the exception of emergency or urgent care situations. The private contract between the LCSW and the Medicare enrollee must state that neither party will seek reimbursement from the Medicare program.  The clinician is then free to charge the Medicare enrollee his/her customary fee.

Additionally, any Medicare-enrolled LCSW who has not submitted a Medicare claim for 12 consecutive calendar months will be disenrolled from the Medicare program. LCSWs can reapply after being dropped from the Medicare provider list to become a provider again, if they so choose (Medicare Reimbursement for LCSWs: Past, Present, and Future, access, 10/06).

LCSWs are used to thinking about how to get onto insurance panels, not about how to stay off them.  Here are some of the reasons that LCSWs may want to opt out of being a Medicare provider:

• An LCSW does not want to complete the Medicare application process, which is lengthy and complicated.
  
• An LCSW does not feel qualified and/or have an interest in working with older patients.
  
• An LCSW does not want to submit claims electronically, as Medicare claims must be in the near future.
  
• An LCSW does not want to comply with accepting all Medicare patients who want to work with the LCSW.
  
• An LCSW does not want to learn the specific complex Medicare requirements for reimbursement submission, including co-insurance.
  
• An LCSW is unwilling to accept Medicare reimbursement rates.
  
• An LCSW is concerned about the 40% co-pay currently in place for Medicare enrollees to access mental health services and the hardship this represents for those on limited incomes [which will gradually reach the 20% co-pay for medical benefits by 2014].

{Article written by Laura Groshong, LICSW, CSWA Director, Government Relations} ©CSWA2010

While it is true that the application process is lengthy and complicated, and the opt-out process also takes some work, the Social Security Law as of 1990 states that all LCSWs must “opt-out” of Medicare if they choose not to “opt-in”, i.e., become an official Medicare provider. This law is not one with which most LCSWs are familiar. Title XVIII, Section 1848(g)(4) of the Social Security Act requires physicians, suppliers, and other persons to submit claims for services rendered to Medicare beneficiaries on and after September 1, 1990. The URL ishttp://www.ssa.gov/OP_Home/ssact/title18/1848.htm.

Ignoring the Medicare system as an LCSW, psychologist, or psychiatrist is not an option under the law, though many clinicians have done so.  The whole concept of having to “opt-out” of an insurance panel is alien to the mindset of trying to get on them; many LCSWs have been shut out of private insurance panels for which they would like to be providers.  Nonetheless, it is important to make an informed decision about opting in or opting out of Medicare or ignoring the system. 

We urge all LCSWs to follow the laws regarding Medicare and opt-in to the Medicare system or opt out.  The URL for opting in to the Medicare system is http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp, which will take you to the PECOS Medicare enrollment page for LCSWs, Form 855i.  There are several fact sheets which are worth reviewing.  As LCSWs, we are “non-physicians” in the Medicare system, and those are the documents that should be used.

Information about opting out of Medicare can be found at http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf.  There is no form supplied by CMS, just instructions on what must be included in a letter that will allow you to opt out.