Recently an OPA member asked me about regulations associated with providing psychological services to clients covered by Medicare. In helping this psychologist sort through the complex options and legal requirements, it became clear to me that many of our members could benefit from extra support and information on this topic. Since anyone who is a licensed psychologist in Ohio potentially can be a Medicare provider, they are affected by the laws that govern their interaction with Medicare clients.
Federal regulations state that a licensed psychologist may choose to either enroll as a Medicare providers or “opt out.” Enrolling as a Medicare provider means the psychologist agrees, among other things, to accept the Medicare-approved amount as full payment for covered services. “Opting out” means that the psychologist submits an affidavit to Medicare agreeing neither the psychologist nor their client covered by Medicare will submit the bill to Medicare for services rendered. Instead, the client will pay the psychologist out-of-pocket and neither party is reimbursed by Medicare. Once a psychologist has opted out, a private contract must be signed between the psychologist and the client covered by Medicare before psychological services can be provided. The contract must state a number of important points, including that neither can receive payment from Medicare for the services that were performed. This contract must:
- Be in writing and in print sufficiently large to ensure that the client is able to read the contract
- Clearly state whether the psychologist is excluded from Medicare.
- State that the client or his or her legal representative accepts full responsibility for payment for the physician’s or practitioner’s charge for all services furnished by the psychologist.
- State that the client or his or her legal representative understands that Medicare limits do not apply to what the psychologist may charge for items or services furnished by the psychologist.
- State that the client or his or her legal representative agrees not to submit a claim to Medicare or to ask the psychologist to submit a claim to Medicare.
- State that the psychologist or his or her legal representative understands that Medicare payment will not be made for any items or services furnished by the psychologist that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
- State that the client or his or her legal representative enters into the contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the client is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
- State the expected or known effective date and expected or known expiration date of the opt-out period.
- State that the client or his or her legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
- Be signed by the client or his or her legal representative and by the psychologist.
Once a psychologist has opted out, the opt out status lasts for two tears, and is renewed automatically at the end of the two-year period. The opt out status may not be terminated during that period unless the provider is opting out the very first time. In that case, the opt out may be terminated within the first 90 days of the period. These opt outs may be cancelled by notifying Medicare before 30 days prior to the beginning of the next two tear period.
Medicare offers a handout available in PDF format summarizing these requirements, including an opt out affidavit form. It can be downloaded here: https://www.cgsmedicare.com/partb/enrollment/part_b_optout.pdf
Completed affidavit forms should be sent to:
CGS Administrators, LLC
J-15 Part B Provider Enrollment
PO Box 20017
Nashville, TN 37202
I can also be contacted directly for a copy of this handout.
My hope is that this summary answers most questions for our members on this topic. However, I understand questions about specific situations may arise. Please feel free to reach out to me directly (firstname.lastname@example.org) if you need more individualized support.
Jim Broyles, PhD
Director of Professional Affairs
Ohio Psychological Association