What Do Therapists Need To Do About Medicare? Opting in or out for 2024: An interview with Joy Alafia, CAE
Curt and Katie interview Joy Alafia, Executive Director of California Association of Marriage and Family Therapists, on the journey for MFTs and Counselors to become eligible to be Medicare providers. We look at the high-level tasks that every therapist needs to take. We also talk about the decision-making process for whether you should opt in or opt out, providing some basic guidance and resources on the steps you need to take now.
Click here to scroll to the podcast transcript.Transcript
An Interview with Joy Alafia, CAE, Executive Director of CAMFT
Joy Alafia is the Executive Director of the California Association of Marriage and Family Therapists. She brings over 17 years of association experience, specializing in transformational leadership, organizational management, and partnership development. Since joining CAMFT, the organization has developed a two-year strategic plan, published the organization’s first Diversity, Equity, and Inclusion (DEI) statement, and passed historic legislation; including California’s Deadname Act which protects MFTs’ privacy and safety by ensuring the DCA no longer recognizes their deadname and the Mental Health Access Improvement Act that identifies MFTs as eligible Medicare providers.
Her employment history includes serving as the CEO of the Western Propane Gas Association (WPGA), where she led the organization to a new chapter focused on renewable propane as part of California’s clean energy economy. Joy previously served as an advisory member for the California Energy Commission’s Clean Transportation Program which supports the accelerated development and deployment of advanced transportation fuels and technologies. Prior to that, Joy served as a Business Director for the California Association of REALTORS®, an organization with over 185,000 members where she focused on developing innovative and enterprising business partnerships.
Joy presently serves on the Board for the United Way Bay Area and previously held a Board position for the non-profit Building Diversity in Science. She has a BS in Physics from Spelman College and an MBA from Pepperdine University. Joy is a Certified Association Executive.
In this podcast episode, we talk about MFTs and Counselors becoming Medicare Providers
Curt and Katie have spent hours in advocacy efforts for MFTs and Counselors to become Medicare providers through their past involvement in the California Association of Marriage and Family Therapists (CAMFT). And it’s finally gone through! We asked Joy Alafia to come join us to discuss this journey as well as what therapists need to do now that we’re eligible to be Medicare providers.
What was the process for MFTs and Counselors to be included in Medicare?
“CAMFT worked with 15 different associations…and collectively created the Medicare Mental Health Workforce Coalition, which consisted of a group of lobbyists, association staff, and it was further bolstered by…the members [of our respective groups] being able to tell those compelling stories of why this was important and those connections that individual members were able to make with our legislators was very instrumental in getting this legislation passed.” – Joy Alafia, CAE
- Almost 25 years of advocacy
- Medicare Mental Health Lobby
- Impact of the pandemic and mental health needs of society pushing us toward the finish line
“A big challenge [in getting mental health providers into Medicare] was the concern about costs…We finally had a moment in this country where there was bipartisan support and recognition that mental health issues affect a lot of people and it’s not a red or a blue issue. It’s something that needs to be addressed.” – Joy Alafia, CAE
- The importance of mental health providers accepting Medicare due to the huge needs and access concerns
Now that Marriage and Family Therapists and Counselors are eligible to bill Medicare, what do we need to do?
- Opt in or opt out – don’t do nothing
- If you are going to opt in, you must decide if you’d like to do straight Medicare (fee for service) or Medicare Advantage (billing Medicare through private insurance panels) or both
- If you are going to opt out, you have to complete the required paperwork to officially be removed from the Medicare rolls.
What do therapists need to do if they would like to Opt In to provide Medicare services?
- Make sure you have the correct NPI number (NPI 1 for sole proprietors, NPI2 for corporations including both individual and group practices)
- Verify that your identity is correct in NPPES (National Plan and Provider Enumeration System) (everything must match exactly to the current information)
- Apply for Medicare in the PECOS system
- Include in your application every state where you are licensed as well as whether you’re in the Counseling Compact or Psypact
- If you’d like to add Medicare Advantage to your current insurance panels, let them know you’re opting in
- If you do not want to bill Medicare Advantage to your current insurance panels, let them know you’re opting out of billing Medicare within each of your contracts
- Once approved, you need to add your Medicare status to your informed consent
- Make sure to set up your billing appropriately wherever you bill insurance (EHR or insurance billing software)
What do therapists need to do if they would like to Opt Out of billing Medicare?
- Find the MAC (Medicare Administrative Contractor) or MACS for all locations where the therapist is licensed to provide therapy services
- Obtain each specific Opt Out Affidavit from each MAC (Sample from Noridian – MAC for CA)
- Complete these forms and mail them in to each MAC you need to notify of your Medicare Status
- Add your Medicare status to your Informed Consent
- Create/obtain a Private Contract to provide to each of your clients who is Medicare eligible, so you can bill private pay for these clients (Sample from Noridian – MAC for CA)
- Your opt out is for 2 years and will automatically renew
- If you’d like to Opt In later, you will have the option up to 30 days before your automatic renewal, but cannot opt in before the 2 year period is up
- At your opt out renewal, you will need to have your Medicare-eligible patients re-sign their private contract with you
What should therapists consider when deciding whether to take Medicare?
- Clinical specialty – if you work with folks 65 and older or with disabled folks, you will want to strongly consider taking Medicare as these clients are typically eligible and would like to use their insurance
- Access – if you have the ability (i.e., space in your caseload) to see Medicare patients, there is a huge need for providers who accept this insurance
- Credibility – there is increased credibility as a provider when you are able to take Medicare
- Rates – check out what the rates are for the areas where you see clients. To do so, look for your locality on the Physician Fee Schedule and multiply the rates by 75% if you’re a masters level provider. If the rates are sufficient, you will consistently get clients and will consistently get paid. If the rates are not sufficient for your business, you will want to consider opting out and remaining private pay for these clients.
- Documentation requirements – the documentation requirements are similar for most insurance plans, especially Medicaid. If you’re able to keep clean, efficient documentation, this should not be a deterrent for taking Medicare
- Billing complexity – you will want to make sure to take trainings available (see below) to understand how you will need to bill this insurance plan and/or hire a biller who does
- Consistency and recession-proofing your practice – Medicare is known to pay consistently and provide a lot of clients for your practice. As the population ages, this will be a larger and larger portion of the folks seeking mental health services. You may want to consider taking Medicare.
Resources for Modern Therapists mentioned in this Podcast Episode:
We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!
California Association of Marriage and Family Therapists (CAMFT)
California Association of Marriage and Family Therapists (CAMFT)
CAMFT’s Medicare Corner (for CAMFT members)
Centers for Medicare & Medicaid Services (CMS)
CMS: FAQ sheet for LMFTs and LMHCs on Medicare
CMS: Physician Fee Schedule (masters levels clinicians get 75% of rates listed)
CMS: Finding the contact information for your MAC
CMS: Licensure Compacts (i.e., Counseling Compact) and Medicare Enrollment
Other Resources
Medicare Credentialing information from Gabrielle Juno-Villani, Medicare Consulting for Therapists
Medicare Updates from Barbara Griswold, LMFT, Navigating the Insurance Maze
How to Opt Out of Medicare from Miranda Palmer of ZynnyMe
Sample Opt Out Affidavit from Noridian Healthcare Services (MAC for California)
Sample Private Contract from Noridian Healthcare Services (MAC for California)
NPPES (National Plan and Provider Enumeration System)
Relevant Episodes of MTSG Podcast:
Making Sense of Insurance Billing and Client Referral Services for Therapists
Should Private Practice Therapists Take Insurance?
Busting Insurance Myths: An Interview with Barbara Griswold, MFT
Is the Counseling Compact Good for Therapists?
The January 2022 Surprise of Good Faith Estimates Requirements
How to Be Accessible Beyond the Sliding Scale: An Interview with Lindsay Bryan-Podvin
Advocacy in the Wake of Looming Mental Healthcare Workforce Shortages
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:
Consultation services with Curt Widhalm or Katie Vernoy:
Connect with the Modern Therapist Community:
Our Facebook Group – The Modern Therapists Group
Modern Therapist’s Survival Guide Creative Credits:
Voice Over by DW McCann https://www.facebook.com/McCannDW/
Music by Crystal Grooms Mangano https://groomsymusic.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements).
… 0:00
(Opening Advertisement)
Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide where therapists live, breathe, and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm, and Katie Vernoy.
Curt Widhalm 0:15
Welcome back modern therapists, this is the Modern Therapist’s Survival Guide. I’m Curt Widhalm, with Katie Vernoy. And this is the podcast for therapists about the things that we do in our practice, the ways that we serve clients. And this is a timely episode on for those MFTs and PCCs out there who are now eligible come January 1 of 2024 to accept Medicare as a payer in your practices. These are steps that you have to do, regardless of whether you opt in or opt out of accepting it, how you might get to the decision of whether you should opt in or opt out, and all sorts of other wonderful information that we’re presenting to you. So, that way you can get it done before January 1. Part of our episode today, we are joined by Joy Alafia, the executive director from the California Association of Marriage and Family Therapists. And I’ll also give credit to my wonderful co-host here, Katie Vernoy, who is done a lot of research into this and is going to guide us through all of the ins and outs and leave you with absolutely no questions left whatsoever with all of her expertise.
Katie Vernoy 1:30
I don’t think that’s actually true, we’re gonna, we’re gonna give you some broad strokes and at least get you a little bit closer to the decision and the steps you need to take plus, we’ll have some great links in the show notes to help you if you need to figure this stuff out.
Curt Widhalm 1:43
And so our first part of the episode here is with Joy Alafia. So, thank you very much for joining the show.
Katie Vernoy 1:51
We’re so excited to have you joy. It’s been wonderful to get to know you as our, I guess, not quite new Executive Director for the California Association of Marriage and Family Therapists. But we’re going to start with a question that we ask all of our guests, which is who are you? And what are you putting out to the world?
Joy Alafia 2:08
Thank you, Katie. And first, let me just share how delighted I am to be with you and all of your listeners. It’s just really an honor to be part of your podcast. I’ll start a little bit about me, I have a background in the sciences, a degree in physics, and later on, went to obtain an MBA. So, I would say I had a rather circuitous path and to the association world, but I would say it’s one where all of my experiences seem to aggregate for good use. So, it’s been very beneficial for me. I believe in the power of associations to create community through our members and having those members really align for a mission that yields societal benefits. I mean, that’s really what it’s all about. I’m also rooted in the integration of DEI Plus. The way I see it and bracing, that framework of diversity and empowerment is really a way to address some of our most pressing needs.
Curt Widhalm 3:03
So, Katie and I have talked about our efforts to get Medicare passed in the past. And we’ve shared about some of our trips to DC and even visiting some of our local representatives’ offices in our advocacy over the years. And we are not the only ones who have put some work into this. We are but a small piece of the greater picture of getting Medicare passed for MFTs and PCCs. Can you help us to kind of help frame what is some of the history that isn’t just Katie and me having done some of this work?
Joy Alafia 3:39
Yeah, well, first, thank you for being part, I look at almost like a marathon where you’re just passing the baton to the next group of volunteers and folks to really see how we can get this across the finish line. When I first joined CAMFT, I had a great interaction with a member and that member shared ‘If you don’t get Medicare done, I don’t know if I’m going to be a member anymore.’ Which…
Katie Vernoy 4:02
Oh wow.
Joy Alafia 4:02
…thought the gauntlet has dropped. That’s pretty easy. It seems like this has been a perennial issue, right. And it was no small undertaking. So, just to give some context, the legislation was first introduced in 1999. So, you’re looking at nearly a quarter of a century to get it passed. And I’m so glad that we were able to finally get it passed. So, you both know, you were kind of part of that inside bulk. CAMFT worked with 15 different associations and also worked with AMPT as part of those associations and collectively created the Medicare Mental Health Workforce Coalition, which consisted of a group of lobbyists, association staff, and it was further bolstered by really the work of our respective members and the members being able to tell those compelling stories of why this was important, and those connections that individual members were able to make with our legislators was very instrumental in getting this legislation passed. You know, as you shared, we would go to DC every year except for the COVID years to advocate and meet with our elected officials. And sometimes we’d see legislation pass in the Senate, but not in the house or vice versa. So, it finally pulled together in 2022. You know, I’ll say there’s a lot of reasons for this legislation, not the least of which is access. There are so many Medicare patients, mostly those over 65, who are without any mental health care. And for some Medicare beneficiaries, there are studies that have shown that there are areas of the US and even in California where a patient would have to travel three hours or more to find someone who could even take them as a Medicare patient. So, much less having room for them in our caseload.
Katie Vernoy 5:56
I think there’s an importance for the these masters level clinicians haven’t been Medicare providers before, this is the counselors and the marriage and family therapists. But why is it important for those of us who weren’t Medicare before to understand what inclusion in Medicare, what it means to us?
Joy Alafia 6:15
You know, perhaps I’ll start with just the sheer number of individuals whose lives will be transformed by this legislation. So, there are over 275,000 additional mental health professionals who will be able to provide services to over 65 million Medicare beneficiaries across the country, and 6.6 million of those beneficiaries are residing right here in California.
Katie Vernoy 6:41
That’s huge. That’s so big. I mean, to me, it seems like there’s such a need. It just, it’s crazy to think how long it took for us to get there, almost five years. Like that’s, and and being there, you know, talking to folks it was they weren’t clear on why MFTs should be involved or why counselors should be involved. And then there was the cost, like if we give more insurance, more people are going to use it, and then it’s going to cost more, which is ridiculous. It’s really important to just honor the work that CAMFT and AMFT have done and ACA and all of the lobbyists because I think it’s it’s so powerful, that we finally got this across the finish line. What does it mean now, with with what the legislation is? Like how do we understand this as as our responsibilities now as potential Medicare providers?
Joy Alafia 7:33
I want to if I can just jump in on one point that you you raise in terms of the passage. And I do see that a big challenge was the concern about costs, right. I think we finally had a moment in this country where there was bipartisan support and recognition that mental health issues affect a lot of people. And it’s not a red or a blue issue. It’s something that needs to be addressed. And the cost part of it, as I understand it, historically has been a huge barrier to getting this legislation passed. And when we look at the numbers one in four, approximately one in four Medicare beneficiaries have a mental health challenge or as substance use disorder. But then only 14% of these beneficiaries receive any mental health services. And then the issue is even exacerbated when you look at mental health disparities for historically marginalized communities. And so I think the framing of this for the politicians and the legislators was that we’re paying for this regardless. So, it makes more sense to invest in providing the care on the front end, versus, you know, what can potentially happen, the different types of ways mental health crises manifest for an individual and even in society when you’re not able to care for these individuals. We MFTs in California are the largest behavioral health provider in the state comprising 55% of the behavioral health workforce in California. So it’s, it is surprising that it took this long, but at the same time, I think it took an awareness of both the cost benefit and the need in our country to bring it to this level. So, I would say in terms of what if I’m getting to your question, hopefully I remember it. For MFTs inclusion in Medicaid Medicare is is meaningful because it really legitimizes MFTs and the expert care that MFTs are so capable of providing. Whether it’s mental health or trauma therapies, to our most vulnerable populations. And I would say for those MFTs who are listening, the important thing that they need to know is whether to opt in or opt out.
… 9:52
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Curt Widhalm 9:52
All right, let’s dive in on that. People are dying to know. We’ve started to see like you need to do something. Let’s talk about kind of the the process of signing up. Because even just doing paperwork or going through government forms might be reasons that people just choose to opt out in the first place. But practically, what does it look like to sign up right now?
Joy Alafia 10:15
That’s an important question. There are really two ways. First, LFTs or counselors who wish to work directly with Medicare, they can do so in the original fee for service Medicare Part B system that they must enroll in with CMS. And they can do that either using the PECOS system. And that’s CMS’s application program, or the paper application, and I would really encourage folks to use the online system, because paper obviously will just take longer. And if you have any errors in that application, it’s just going to be harder to correct that versus the online, you’ll get some of that feedback, real time.
Katie Vernoy 10:54
We can put links to these things in our show notes over at mtsgpodcast.com.
Joy Alafia 10:59
Thank you. And it’s a little bit of an alphabet soup. So you know, go to our Medicare corner where folks can see, you know, some of the FAQs there as well. The other way to get involved is to go through your insurance companies. So, for those who wish to work and the Medicare Advantage Medicare Part C system, they’ll need to reach out to the Medicare Advantage plan or plans they wish to contract with. So, for example, BlueCross and, or else can expand already existing contracts that they have to see Medicare beneficiaries. There’s a list of the Medicare Advantage plans and their contact information that can be found on CAMFTs Medicare corner in the Medicare Advantage section, as well as CAMFTs Medicare provider enrollment guide.
Katie Vernoy 11:50
And we’ll put those in our show notes, too.
Curt Widhalm 11:52
What if somebody is really busy and doesn’t opt in or opt out? I understand that this is possibly the worst position to be in. But what happens if you just kind of don’t do anything as it pertains to Medicare?
Joy Alafia 12:06
Well, you, we really hope that your listeners and they share within their community of MFT’s and counselors that you have to do something. Waiting and doing nothing is really not an option. The concern is that a patient might bill through Medicare, and the provider may be found to have fraudulent billing. And so that’s really what we’re trying to address. And and when that occurs, you might have to reimburse the client for the fees or there may be other actions. So really, it’s important to make sure you opt out if you know you do not want to see to use Medicare.
Curt Widhalm 12:47
I was prepared to make a joke that the Medicare police were going to come after you but that actually sounds like what happens if you actually don’t do anything.
Joy Alafia 12:58
Yeah, you know, I don’t know what this really looks like in practice. But do you want to chance it? So, you know, as of January 1, all LMFT’s become Medicare and counselors become Medicare eligible providers. So really, this means you have to take some affirmative action, even if you decide you do not want to be part of the Medicare system. So, the term opted out provider means the provider has chosen not to participate in in Medicare. And LMFTS, who choose not to be involved in Medicare, but do not take appropriate steps to opt out, you know, you could be accused of insurance fraud and wind up having to again refund payments for services to patients who are Medicare beneficiaries.
Katie Vernoy 13:42
So, you have to you have to opt out or you’re still considered kind of in this gray area where you’re not quite a Medicare provider, but you’re not not a Medicare provider.
Joy Alafia 13:53
Correct.
Katie Vernoy 13:53
So, how do you opt out?
Joy Alafia 13:55
This is when I say go to our website. Find out more. But it’s a two step process. And you know, we have information on CAMFT’s Medicare corner about what that specifically looks like. So, it should not be too difficult. And but you do need to take action.
Katie Vernoy 14:14
We either have to opt in or opt out. If we don’t opt out the Medicare police might come after us. So, I have some some Medicare clients or they’re Medicare eligible clients and I currently see them private pay. If I decide to opt out, can I still see them?
Joy Alafia 14:32
Yes, you can actually. So, you can treat a patient who has a Medicare beneficiary, even if you’ve opted out of becoming a Medicare provider. Opted out providers would just want to make sure to inquire at the outset of treatment, whether the patient has Medicare. So, we’ve had a lot of providers assume they only need to discuss the issue with patients 65 and older. And that’s not the case. You know, there are other conditions that that qualify to be a Medicare beneficiary. So, so if you are seeing someone who is on Medicare and you have opted out, you will just need to have them sign a consent form indicating that they understand that you do not accept Medicare.
Katie Vernoy 15:15
Okay, that seems easy enough. So, going back to those of us who have opted in, so to speak, what are the reimbursement rates going to be?
Joy Alafia 15:23
Original Medicare fee for service rates are determined by the physician fee schedule, which is revised annually. So, to get an idea of what those payments amount to members can use CMS’s provider payment lookup tool. And I’m sure you’ll have a link to that.
Katie Vernoy 15:39
We will.
Joy Alafia 15:40
To determine exactly what they would be paid, since the rates ultimately depend on the geographic location, and if they’re working in a facility, or non facility setting. Medicare Advantage rates are determined by the Medicare Advantage plan. So, providers should contact their Medicare Advantage plans they are considering working with to get a copy of the plans fee schedule.
Curt Widhalm 16:03
What types of services are going to be covered? Is this just where there’s only going to be one CPT code? Or is this something where, especially for people who work in family systems kind of work or couples work, what are the available options that are there for providers?
Joy Alafia 16:21
Well, it’s the whole gamut. As you know, MFTs, and counselors are able to treat anything from the DSM. And now they can provide all of those mental health services through Medicare. So CMS’s Medicare Learning Network publishes a helpful booklet titled ‘Medicare and Mental Health Coverage’. And when you go to pages 22 and 25 of that booklet, it lists the CPT codes Medicare covers, and/or pays for. The physician fee schedule final role also adds crisis codes to the list. So, really want to look at that booklet, it’s soon to be updated to reflect the final role, which spells out exactly what the payment will look like for 2024. And the meantime, CAMFT is publishing an article summarizing the final roll which can be found on again, you guessed it our Medicare corner.
Katie Vernoy 17:14
We’ve got: we need to opt in or out, we need to make sure that we’re paying attention to you know how this works, potentially going straight through Medicare or the Medicare Advantage plans. Am I missing anything? What are the real responsibilities for the Masters level clinicians at this point?
Joy Alafia 17:31
Well, if I haven’t made this absolutely clear, the main responsibility would be to take action to do something, either enroll, and make sure you enroll properly or opt out. But please do something. Take action here and tell your friends to do the same to make sure they go to our website and get educated on this. We have free webinars on the variety of options, what it looks like that you can share those. We cannot impress enough on your listeners, the important that all counselors and MFTs take action to protect themselves.
Curt Widhalm 18:08
Is there anything else that MFTs and counselors need to know about Medicare that we haven’t covered yet?
Joy Alafia 18:13
The one caveat, I’ll also share, as we’re learning more every month, and we’re still as an association, we’re interacting with CMS and getting clarity. So, things can potentially change. We don’t see major changes and certainly not a change to the rule that has been released. But how it’s implemented, as we continue to educate CMS, there may be some clarification there. So always visit our website. We update our website as well as when we get new information so that you know the providers also will have that information. Any provider working on the original or the fee for service Medicare Part B side should make sure to just to subscribe to their Medicare administrative contractors at the MAC newsletter, and attend MAC provider trainings. Providers working in the Medicare Advantage system should be sure to obtain access to the Medicare Advantage plans providers portals, review their providers contracts, and the plans provider handbooks or manuals. They may also want to sign up for the plans, provider newsletters as well. And keep their eye out for any communication from the plans.
Curt Widhalm 19:28
Thank you for your time today and sharing all of this where can people find out more about you and CAMFT and the webinars and resources that you have going on as it pertains to not only this, but all of the wonderful things that CAMFT does?
Joy Alafia 19:44
Yeah, that’s a great question. Thanks for the plug. And I would say go to our website. So camft.org/medicare. That’s our Medicare corner. There’s so much information there. But we attempted to organize in a way to answer all of those pressing questions that newly enrolled providers or those that want to opt out would have. So, go to our website camft.org/medicare. And I think we highlighted a few other websites as well. And you could find those also, within the camft.org/medicare website.
Curt Widhalm 20:23
And we’ll include links to that, as well as the other resources in our show notes over at mtsgpodcast.com. Thank you for all of your time and wonderful wisdom with us.
Joy Alafia 20:36
Thank you for having me, for the opportunity. We’re just really excited about this and the number of patients that therapists and counselors can serve and certainly want to get the word out. And I hope that more people are able to enroll and help with the the critical need that we see in this population. So thank you for the opportunity to share.
Katie Vernoy 21:01
It was really good to talk to Joy. I think it gives us a good overview of what the journey was to get to Medicare. And I am so excited that MFTs and counselors take Medicare as as providers because I think it adds credibility. That being said, I don’t know that being a Medicare provider is for everyone. And so the decision actually is a bit more challenging. What questions have you started mulling over for yourself and your practice as far as whether you would take Medicare or not?
Curt Widhalm 21:32
Some of the things that we’ve discussed in our group practice is: what is going to be the requirements as far as documentation, paperwork, that kind of stuff? That’s been a big concern. We’ve been private practice and while, we have a fairly robust documentation internally, since we’re not in network with any insurance plans as it is, a lot of our documentation is for our records, our legal protections going forward. We’re not necessarily already in a billing system already. We also are really evaluating, do we have the capacity to even offer more spots to people? We have the fortunate problem of, we’ve got a full case practice that is entirely private pay, and with super bills and that kind of stuff. So for us, it’s really a lot more capacity questions at this point that is making us look at is this something that makes sense for us? And then when we looked at the reimbursement rates, they don’t really match up with what we are already charging our clients anyway. So it’s kind of like, are we really looking at offering more accessibility to clients? But do we even have the space to offer more accessibility to clients, if we can’t even give them sessions in the first place?
Katie Vernoy 22:53
All of those are really good points. I’ll kind of go through them and add some other ones that I’ve seen too, because I think it’s really critical to understand what it would mean to your particular practice to take Medicare. So, the first one is the documentation. I’ve heard that in applying for Medicare, there’s a lot of stuff to do. And we’ll talk about kind of the steps of it after we get through the decision making process. What we’re really talking about is whether or not you can kind of get through detailed application processes. Yes, there is a bureaucracy. I’ve heard folks say it’s a little bit of a, of a nasty process to get there. But once you’re in, it’s fine. And for folks who are already taking Medicaid, it’s it’s through the same system, you’re probably already good to go. You just have to do the application that’s specific to Medicare. And so it’s it’s something where if the paperwork is a big problem, I would really assess is it just that you hate paperwork? Or you think you might be bad at it? Because if you’ve ever taken Medicaid, whether it was at an agency or whatever, if you’ve ever taken insurance, if you have a robust documentation process, I think the documentation isn’t horrible. And I’ve heard tell that, you know, audits actually aren’t a huge thing, especially for direct Medicare versus the Medicare Advantage. Private insurance companies actually are more likely to audit than Medicare is thing I’ve heard. So, I don’t know if that’s true. But but the the paperwork itself may not be as big of a hurdle as folks might think. Now, rates could be. And so I think it’s really important to understand what your rates are. And I know we’ve talked about, you know, in the cardigan cartel, we can’t, we can’t share rates, but actually they are listed. And we’ll we’ll put links to this in our show notes. But you can actually go through, identify where your clients are and that would be something where it’s going to the rates are going to be based on where your clients are, and see what the rate is. And they’re the same across the board. There’s no negotiation. The thing that you want to pay attention to as as a master’s level clinician, you have to multiply whatever the rate is by 75 percent, which brings it down to, you know, the ones I’ve looked to are somewhere in the $100, maybe $120 range for the 90837. And a lot of them in the 90834 are more like the $80 range. And granted do not quote me on those because it’s very different per location. But and it’s different locations within the MAC’s that that joy was talking about. So, it’s actually like Los Angeles, versus San Diego versus Orange County versus Phoenix versus, you know, New York City. Right?
Curt Widhalm 25:36
Right.
Katie Vernoy 25:37
So, it’s a little bit of a process, especially if you’re doing telehealth, and you’re licensed in a number of states, but you’re gonna get a sense that the rates are what they are. And you have to decide if that fits for your practice. For some folks, if they can get $110 a session, and they can fill up their whole practice that works for them financially. For other folks who are living in places with higher cost of living, and that’s the rate, it may not be manageable for their practice. And so that’s a really individual decision. It sounds like in looking at yours, you guys are in a higher cost of living area, that kind of stuff, it’s going to that’s, that’s a tipping point for you.
Curt Widhalm 26:13
Right.
Katie Vernoy 26:14
It does add a lot of access. And so I think you’re right, but if you don’t have space for clients, becoming a Medicare provider doesn’t necessarily help anybody. That’s a really good point. But if you’re newer in a practice, then there’s that element of being able to really fill up a practice with folks, especially if they’re in your your niche or your specialty area. If you work with older folks, or if you work with folks with disabilities, being able to accept their insurance is huge, and potentially means that you can have a really free flowing stable practice with the folks you like to see. And, you know, you’ve won’t have to market. You can, you know, you’re you’re guaranteed to get paid. It can get delayed at times, but it’s it’s a consistent pay from what I’ve heard of other from other Medicare providers. And so I think it’s, it’s important to look at the specifics for your practice. So decision making wise, so just to summarize this decision making wise it’s: is this important for the clients that you want to see? Are you at a stage where you can actually provide access and have some spaces to fill with folks that would be wanting to use this insurance? It is a way to kind of recession proof your practice, because there are more and more folks for whom Medicare is their insurance, you know, with the boomers aging into the system, so to speak. And I think there’s also that element of can my practice handle the clients that would be coming in? So, we’re looking at older clients. So you need to have those types of specialties, whether it’s dementia or grief or medical concerns, that kind of stuff. And then there’s also folks with disabilities and some of those disabilities can be severe mental illness. And so looking at what can you handle within your practice? And what are you set up to do? So there’s clinical implications, there’s fee implications. We’ll have links to some of the tools to make that decision in your in the show notes. But I think we’ve covered how someone might make a decision. What do you think?
Curt Widhalm 28:15
If you have more then I think you probably should have longer conversations than just listening to us in a brief portion of a podcast.
Katie Vernoy 28:26
And we’ll link to a couple of folks who have really good resources. We’ve had Barbara Griswold on before. She’s been doing some stuff in her Navigating the Insurance Maze. We’ll link to you know, a specific blog that she has up about that. I’ve also started to look at Gabrielle Juliano-Villani’s stuff, and she actually is a Medicare consultant for folks. And so they have, I think even more detail about how you might make the decision. And then even as we move forward, we’re gonna give some basics, but they’ll have the details on how to enroll should you want to enroll.
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Katie Vernoy 29:02
So okay, so moving from how to make the decision. Now if you’ve made the decision to opt in, then you have to apply.
Curt Widhalm 29:10
i It’s not just like click a couple of boxes and let those Medicare clients come rolling into our offices.
Katie Vernoy 29:17
Oh, if only it were, if only it were. No, I think that the first thing is if you’ve not if you’re not on Medicaid, you may have to go into the the system where NPI is, where you looking at your NPI, where your identity theft stuff is and make sure that everything is exactly the same. I had this issue because I was briefly a Medicaid provider. And I my my practice name didn’t line up with my name. And so I had to go back and officially get my DBA to make sure that lined up. Like I had to make sure the address, the name of the business, like all of this stuff lined up exactly before I could even actually start the application process. Or or I started the application process and they’re like, whoa, whoa, whoa, we can’t prove that you’re you. So the first thing is to make sure that your NPI actually lines up with you and that your whole business lines up and everything is the same. So if you’ve moved and your address changed, you would need to change the address in all of these systems. And so this is the kind of stuff that’s a little bit beyond kind of the scope here. So we’ll put links to folks that can talk you through applying. But just to kind of get a sense, there’s going to be time to make sure that your information is accurate, then you go to this PICO system and sign up. And that actually might be like a kind of done quickly kind of thing. Joy mentioned that there is a paper process. But yes, you got to use the electronic process, because I started looking through the paper process. And to be honest, I went into the PICO system, I could not remember my password. And then I couldn’t remember why my information wasn’t lining up. And so I was almost locked out. So, I stopped. But so I was like, let me just look at the paper application. I’m like, Oh, my gosh, this is so friggin confusing. Whereas the electronic process is going to have only the questions you need to answer. And it’ll be a lot easier. So make sure your identity is accurate, make sure you sign up in the PECOS process. And actually, that process is actually pretty good. They give you feedback in real time, it’s once you’re in that it’s just like any application. It might be a pain in the butt, but it’s not bad. Then once you’re approved, you actually need to make sure that you have the status in your informed consent. And you’re going to have to do this if you opt out to. So everyone needs to change their informed consent starting January 1st. And then you need to make sure that you’re billing accurately. And some of that’s just getting it set up in your electronic health record system or your electronic billing system. And then it should be good to go. So, that’s what you have to do to opt in. And you have to do it for every MAC where you’re licensed and are seeing clients who take Medicare.
Curt Widhalm 31:53
So with the informed consent, is this just as simple as putting in, ‘I am not a Medicare provider’, or ‘I am a Medicare provider’. Is it just like one sentence that people need to put in there?
Katie Vernoy 32:06
The way I’ve seen it is it looks like it’s a little section and it has the opportunity to kind of gather the information if you are a Medicare provider. And then if you’re not a Medicare provider, there’s like a couple of statements that are required to be put in there.
Curt Widhalm 32:19
Those sounds like great things that we should put in our show notes.
Katie Vernoy 32:23
We will, we will. We have examples from our MAC, and I’ll share those with you. But it’s something where and if you’re a CAMFT member, that CAMFT Medicare corner is great. I’ve saw that AAMFT has stuff, ACA has stuff, NBCC has stuff. So a lot of that stuff you can find in a lot of different places. So we’ll put some stuff in our show notes, and potentially maybe like a list of steps to take as best as we can. But in truth, you know, finishing the opting in part, it’s it’s kind of a slightly more complicated signing up to be on an insurance panel. Now, second, for opting in. So, that’s direct fee for service. If you want to take Medicare for like an insurance plan, like a Medicare Advantage, like the insurance plan that you’re already credentialed with, then you just have to let them know. And if you don’t, let’s say you just want to do fee for service kind of direct Medicare versus Medicare Advantage, then you do have to opt out with each insurance plan you don’t want to take Medicare for. And this is similar to Medicaid. You just have to opt in or out with insurance plans are credentialed with. If you’re new and you’re wanting to apply for everything, you have to be credentialed with an insurance plan to be able to take Medicare Advantage through that insurance plan. Does that make sense? I feel like I’m getting a little complicated.
Curt Widhalm 33:41
I think it makes sense. But I’m also getting the sense that my approach on this is my head’s starting to spin. So clarify, boil this down to a couple of bullet points for our listeners here.
Katie Vernoy 33:54
Okay. If you want to take Medicare, apply for Medicare. We talked about that. If you want to take Medicare Advantage on insurance panels that you are already credentialed with, let those insurance panels know. And they may ask you, right, do you want to take Medicare or not? And you say yes or no. If you’re new, and you want to take Medicare, apply for Medicare, apply for their insurance panels and then opt in or out up on Medicare for those insurance panels.
Curt Widhalm 34:24
Okay.
Katie Vernoy 34:25
All right. So, that’s taking Medicare. Now, as I’m hearing you leaning this direction, I’m leaning this direction: opting out.
Curt Widhalm 34:35
Yes.
Katie Vernoy 34:36
So, opting out, being sure to opt out is really important if you are seeing clients who are on Medicare or you think you might be seeing clients who are on Medicare, and you want to be able to bill private pay. And so what that looks like is that there is a opt out affidavit that you need to do with your particular MAC. And so figure out what your MAC is. We’ll link to the map that shows you what MAC you’re in. And this is where you are licensed and seeing clients, so that you might have several MAC’s you have to do this for. For folks who are licensed in multiple states or part of a, like the Counseling Compact, or the Psypact kind of stuff, because everybody needs to opt in or out at this point, all mental health providers do. Check to see where you need to opt in or opt out. It’s my understanding is if your license, you need to do it in every single state you’re licensed in. With the Counseling Compact or Psypact, those types of things, I think there’s a little bit of a slightly different process. And so I’ll I’ll link to something there in the show notes about, you know, where you need to find that. Potentially, you’re going to need to call your MACs or, or those types of things. I have one that I’m going to have to check into because I’m licensed in two states, and I’m a registered telehealth provider and a third state. And so that’s three different MAC’s. And so the third MAC, the one where I’m registered, I don’t think I need to opt out. But I’m just going to double check. So, I’m going to send a quick email to their to that MAC and see what happens. You actually physically send or fax an opt out affidavit that they’ve provided to you. So you have to print it out, and then sign it. And then once you have been opted out, you want to check, there’s a place to check. And I’ll put that link in the show notes to make sure that they actually got your opt out. And they’re not thinking that you’re somewhere in this gray area. Just to make sure that folks get this if you opt out of Medicare, but you are taking private insurance, you’re going to need to let all of your insurance plans know that you’re opting out of Medicare as well. So, if you’re not a Medicare provider, it’s not like, oh, they just know that. They’re gonna assume that you’re opting in, because you’re an insurance provider. So, you have to opt out everywhere. But I think that’s a one time deal. You need to put your status in your informed consent for everyone. The thing we talked about, like I’m not a Medicare provider, and we’ll have that statement. And then if you have any Medicare patients, and you need to clarify with everyone, do they have Medicare, because it’s not just folks who are over 65, it is also folks with disabilities, that kind of stuff, then you have to have them sign a private contract. Now, at the federal level, they have this is what needs to go into your private contract. At least our MAC says ‘Have them sign this form’, and they’ve created it for us. And so we’ll we’ll link to our MAC’s private contract in the show notes for folks that need to find it. But you need to have anyone who is on Medicare sign that private contract. So, it’s an additional form, you’re going to need to have them sign.
Curt Widhalm 37:45
So, I’m trying to picture how we’re going to implement this in our practice. So, each of us have our own individual informed consents that we will put this language in. In our initial intake questionnaire, we will have a question that is just like, are you in Medicare? Is this a Medicare application thing that you’re doing? And then with a little note right there that says we are not Medicare providers. And then if somebody says that, yes, we are part of Medicare, then we have to give them the separate contract that says, just so you fully finally understand, we are outside of the system, you are paying us privately, here’s all this language from the MAC.
Katie Vernoy 38:27
Yeah, so one of the important parts of that is that they are agreeing not to try to bill Medicare for your services. Because if that happens, then Medicare is going to be mad at you. This is where the Medicare police comes in. Now, if you’ve opted out, and they still try to bill Medicare, that I think it probably just annoys people, I don’t think there’s actually anything there. But if you’re not opted out of Medicare, and one of your patients, applies, you know, tries to get reimbursement from Medicare for your services, they might come after you because you’ve not opted out.
Curt Widhalm 39:00
So, then that would be the purpose of having all of this documentation that I’m envisioning implementing in our practice. That is, these clients had plenty of warning, they theoretically knew. We’ve reminded them from time to time, and we did everything on our end, this is not a practice problem that initiated all of this.
Katie Vernoy 39:25
Yeah.
Curt Widhalm 39:25
Once again, go to here’s all of the documentation that proves that we did what we did.
Katie Vernoy 39:31
But yeah, we did what we were supposed to. Yeah. And and so initially, if you opt in or opt out, so the first time you opt in or opt out, you have 90 days to change your mind. And then you can opt out again, or you can opt in or whatever, right. So, I think for folks who are on the fence, do it anyway, go towards where you’re leaning and then take some time to think about it if you need to within the first 90 days. However, once you are truly opted out, it’s an opt out for two years. And so this is something where were two years, you will not be able to take Medicare. And it will automatically renew. And they’ll let you know a little bit before the renewal date, say, Hey, you still, if you still don’t want to take Medicare do nothing, at least that’s what I’m understanding. If you’d like to take Medicare, opt in now, start the application process. So, I think they they give you an opportunity to opt back in. But it is two years. I don’t think you can be like in a year and be like, oh, you know what, I really wish I was taking Medicare. You’re gonna have to wait. They don’t want these midterm things to to happen. And I think, I’m not sure, this is something that I think we’ll have to look at over time, that when you get to your two year mark, my understanding and I’ll we can double check this and, you know, kind of share information as we go along. You may need to have your clients who are still Medicare eligible, and you’re still doing services with to sign another private contract, each two year period. But it would be for everybody all at the same time, because it’s your two year period, not their two year period.
Curt Widhalm 41:04
For people who have made it: I don’t want to do this, they have to re opt out, even though they’ve opt out. Like this seems…
Katie Vernoy 41:13
Automatically renews your opt out.
Curt Widhalm 41:15
Okay.
Katie Vernoy 41:16
But your private contract with your clients does not. And so as I’m thinking about this, I would just have folks sign, you know, updated forms every year, so you just don’t even think about it.
Curt Widhalm 41:29
By the way, I’m still not part of Medicare. I have to Medicare, who has no governance over me…
Katie Vernoy 41:36
Yeah.
Curt Widhalm 41:37
It’s still making me have you resigned this paperwork.
Katie Vernoy 41:40
Yeah.
Curt Widhalm 41:41
Okay. Just more burdensome, even though you have opted out of the system.
Katie Vernoy 41:46
Yeah. So, there’s the your informed consent. So, if you do any changes, obviously, that’s every year. The good faith estimate needs to be done every year. And now you’ve also got the Medicare opt out form for Medicare patients.
Curt Widhalm 41:59
Got it? Okay. So it’s just a whole new stack of paperwork that you should put out every year?
Katie Vernoy 42:06
Pretty much. That’s what I’m thinking. I mean, I think it can be fairly easy. You know, if you have an electronic health system, where you can kind of put all that stuff into something and like, have somebody sign one thing, and so you’ve got your, your stuff for, you know, folks who are not Medicare eligible, and you have your set for folks who are Medicare eligible. Everybody who signs it at the beginning of each year.
Curt Widhalm 42:25
Okay.
Katie Vernoy 42:27
So, that’s my thought process as I build these things out. Maybe that’s not as easy as I think it is. But to me, it feels like it’s not, as long as your clients, it’s easy, and your clients actually sign these things timely, I think you’re pretty good to go.
Curt Widhalm 42:42
So, if I’m taking away everything from this, it’s imagine that this is the most confusing process possible. Look at all of the conflicting information that you’re getting from everybody, including us. And then still go to one of the very helpful step by step tutorials for a visual process that we will include in our show notes.
Katie Vernoy 43:04
Yes.
Curt Widhalm 43:05
Because once you have decided whether or not to participate in this, whether it makes sense for you, there’s going to be a bunch of steps that you have to do either way that includes setting yourself some reminders for how you follow up with clients on all these kinds of things. And your situation may change and being expected to remember all of this stuff from an auditory podcast is just an introduction to things. But the big takeaway is, there are lots of resources here, we want to make sure that people are at least talking and listening about this. But it’s probably not as confusing as I’m making it if you’re actually able to picture some of this stuff and follow one of the helpful step by step guides.
Katie Vernoy 43:50
And I think for folks who are planning to opt out, if you are not seeing anyone who’s on Medicare, currently, you might have a little bit of time. Because it’s really making sure that you’re not seeing a Medicare patient when you’ve not determined your status. And so, yes, you need to act quickly, and I would act more quickly than you might want to. But this is this is not the big stressful thing that I think a lot of folks are concerned about. Make your decision, take some action, make sure you’re not in in that gray area where you’re seeing Medicaid, Medicare patients and not either opted in or opted out. But otherwise, take a breath it’s going to be okay.
Curt Widhalm 44:34
So you can find our very helpful show notes over at mtsgpodcast.com. Follow us on our social media for some updates on this stuff. Join our Facebook group, the Modern Therapist Group to continue the discussions on this. And until next time, I’m Curt Widhalm with Katie Vernoy, and joined earlier by Joy Alafia.
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