There continues to be confusion about whether providers who are licensed in California, but living elsewhere, are eligible Medicare providers. As you may know, eligible providers need to either opt into Medicare (enroll as a Fee-For-Service provider or work with Medicare beneficiaries through a Medicare Advantage plan) or opt out of Medicare (file an opt-out affidavit and privately contract with patients).  

At the end of May, we met with leaders of the Centers for Medicare and Medicaid Services (CMS) Region 9 Office to obtain more information about this and other Medicare issues.  

CMS’s Regional Office staff could not tell CAMFT whether providers being physically located and practicing from a state where they are not licensed means those providers are ineligible to render services to Medicare beneficiaries. While CMS staff could not offer definitive guidance for CAMFT or its members on the issue, CMS provided the following information:   

1. Licensees who have not opted into or out of the Medicare system should tell their Medicare covered patients that they are not Medicare providers and refer those beneficiaries to providers who participate in Medicare.  
2. Licensed providers who have not opted into or out of the Medicare system and work with Medicare beneficiaries but do not bill the system and enter into private pay agreements with those patients may be contacted by a Medicare Administrative Contractor (MAC) about their Medicare status and may be subject to investigation for violating the mandatory claims submission law found in Section 1848 (g)(4) of the Social Security Act. This code section requires all providers who offer covered services to Medicare beneficiaries to submit claims for all Medicare patients for services rendered, unless those providers have opted out of Medicare.  

We are bringing this information to the attention of our Medicare Mental Health Workforce Coalition and will continue to seek answers from CMS.