Newly Medicare-Eligible LPC: Enroll, Opt Out, or Neither?

Enroll, opt out, or neither: which one applies

Three doors, and which one applies turns first on a fact about your caseload. Medicare has paid mental health counselor services under Part B since January 1, 2024 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. If Medicare beneficiaries will be on your schedule, you either enroll and bill Medicare or opt out and contract privately with each of them. If none will be, CMS says you are required to do neither 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first..

The third door is where most newly eligible counselors are standing without having chosen it. A practice with no Medicare beneficiaries owes Medicare no filing at all 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. But that is a fact about this month rather than a status you hold, and it stops being true the first time a client you want to keep asks whether you take Medicare.

Eligibility for the first door is federal and specific. Medicare's definition of a mental health counselor asks for a qualifying master's or doctoral degree, state licensure or certification as a mental health counselor, clinical professional counselor or professional counselor, and at least 2 years or 3,000 hours of post-master's clinical supervised experience in an appropriate setting 2Ref 2Office of the Federal Register (2026).42 CFR 410.54 — Mental health counselor services..Medicare's regulatory definition of a mental health counselor: the qualifying degree, the state licensure or certification titles, the 2 years or 3,000 hours of post-master's clinical supervised experience stated as alternatives, and the hospital-inpatient exclusion.. The regulation lists the two experience measures as alternatives, so either one satisfies it. The same section excludes services furnished to a hospital inpatient 2Ref 2Office of the Federal Register (2026).42 CFR 410.54 — Mental health counselor services..Medicare's regulatory definition of a mental health counselor: the qualifying degree, the state licensure or certification titles, the 2 years or 3,000 hours of post-master's clinical supervised experience stated as alternatives, and the hospital-inpatient exclusion..

What enrolling commits you to

Enrollment is a set of terms rather than permission to send claims. The fee schedule pays mental health counselor services at 75 percent of the amount determined for clinical psychologist services under the physician fee schedule 3Ref 3Office of the Federal Register (2026).42 CFR 414.53 — Fee schedule for clinical social worker, marriage and family therapist, and mental health counselor services..The payment rule that mental health counselor services are paid at 75 percent of the amount determined for clinical psychologist services under the physician fee schedule, and the fact that the regulation supplies no dollar amount, code or locality., and an enrolled counselor must accept assignment on every Medicare claim 4Ref 4Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.That an enrolled mental health counselor must accept assignment on Medicare claims, which is why no non-participating or balance-billing posture is available to a counselor.. Accepting assignment means the allowed amount is the whole amount, and the gap between it and your usual rate is not billable to the patient.

Counselors inherit the physicians' vocabulary here, and its middle rung is missing. The participation, non-par, opt-out ladder is built for a practitioner who can decline assignment on a claim. mandatory assignment takes that position away 4Ref 4Centers for Medicare & Medicaid Services, Medicare Learning Network (2026).Medicare & Mental Health Coverage.That an enrolled mental health counselor must accept assignment on Medicare claims, which is why no non-participating or balance-billing posture is available to a counselor., so there is no non-par posture to adopt and no balance-billing to plan around. Read any credentialing form asking about Medicare participation with that in mind.

The 75 percent is a percentage of another profession's rate and the regulation states nothing further 3Ref 3Office of the Federal Register (2026).42 CFR 414.53 — Fee schedule for clinical social worker, marriage and family therapist, and mental health counselor services..The payment rule that mental health counselor services are paid at 75 percent of the amount determined for clinical psychologist services under the physician fee schedule, and the fact that the regulation supplies no dollar amount, code or locality.. No dollar amount, no CPT code, no locality. To learn what a session pays where you practice, pull the clinical psychologist allowed amount for the codes that carry your week from Medicare's physician fee schedule look-up tool and take three-quarters of it. Run that on your two or three most-billed codes before the decision rather than after.

Filing is the cheap part. Medicare charges mental health counselors no application fee, and the route is PECOS online or the paper CMS-855I 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. The form-level detail, including which specialty box to use, belongs to 855I enrollment for LPCs and LMFTs and is not repeated here.

What opting out commits you to

Opting out is a two-year status rather than a form you file once. You sign an affidavit and send it to each Medicare Administrative Contractor you would otherwise file claims with, and from then on every Medicare beneficiary you treat signs a private contract with you 5Ref 5Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.410 — Opt-out.The opt-out timing conditions: the affidavit goes to each Medicare Administrative Contractor the practitioner would otherwise file claims with, a nonparticipating practitioner may opt out at any time, and the initial two-year period begins on the signature date only when the affidavit is filed within 10 days after the first private contract is signed.6Ref 6Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.415 — Terms of a private contract.The shape of the ongoing private-contract obligation an opt-out creates: a written contract signed by both parties, entered into for each two-year opt-out period, retained for the period, and not signed during emergency or urgent care.. The affidavit carries your NPI, or your tax ID if none has been assigned, and your agreement that no Medicare payment, direct or indirect, will reach you during the period 7Ref 7Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.420 — Beneficiary's agreement with the physician or practitioner not to bill Medicare.What the opt-out affidavit must contain and what it binds: the practitioner's NPI, or tax ID if none has been assigned, and the agreement to receive no direct or indirect Medicare payment during the period, including as an employee, under a reassignment of benefits, or as payment under a Medicare Advantage plan..

The clock has a trap in it. The initial two-year period runs from the date you sign the affidavit only if it is filed within 10 days after the first private contract is signed 5Ref 5Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.410 — Opt-out.The opt-out timing conditions: the affidavit goes to each Medicare Administrative Contractor the practitioner would otherwise file claims with, a nonparticipating practitioner may opt out at any time, and the initial two-year period begins on the signature date only when the affidavit is filed within 10 days after the first private contract is signed.. Miss that window and the period instead begins on the filing date of the last affidavit, leaving everything furnished in between under standard Medicare rules 5Ref 5Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.410 — Opt-out.The opt-out timing conditions: the affidavit goes to each Medicare Administrative Contractor the practitioner would otherwise file claims with, a nonparticipating practitioner may opt out at any time, and the initial two-year period begins on the signature date only when the affidavit is filed within 10 days after the first private contract is signed.. A nonparticipating practitioner may opt out at any time, so the start date is yours to set. The ten days after it are not.

It also renews itself. The status rolls over for another two years unless written notice reaches your contractor no later than 30 days before the current period ends, and a first-time opt-out can be cancelled early only by notifying the contractor no later than 90 days after the period's effective date 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. There is no standard CMS opt-out form, though some contractors publish a template 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first..

The paperwork does not stop at the affidavit either. Each Medicare patient needs a written contract signed by both of you, a fresh one for each two-year period, retained with original signatures for the duration and produced to CMS on request 6Ref 6Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.415 — Terms of a private contract.The shape of the ongoing private-contract obligation an opt-out creates: a written contract signed by both parties, entered into for each two-year opt-out period, retained for the period, and not signed during emergency or urgent care.. A contract may not be signed during emergency or urgent care 6Ref 6Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.415 — Terms of a private contract.The shape of the ongoing private-contract obligation an opt-out creates: a written contract signed by both parties, entered into for each two-year opt-out period, retained for the period, and not signed during emergency or urgent care.. Two years in, that is a stack of documents keyed to a renewal date nobody tracks for you.

The clause that catches a counselor with a second job

One sentence in the affidavit reaches past your own practice. During the opt-out period you may receive no direct or indirect Medicare payment for privately contracted patients, whether as an individual, an employee, a partner, under a reassignment of benefits, or as payment under a Medicare Advantage plan 7Ref 7Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.420 — Beneficiary's agreement with the physician or practitioner not to bill Medicare.What the opt-out affidavit must contain and what it binds: the practitioner's NPI, or tax ID if none has been assigned, and the agreement to receive no direct or indirect Medicare payment during the period, including as an employee, under a reassignment of benefits, or as payment under a Medicare Advantage plan.. The affidavit binds the person who signed it rather than the tax ID it was signed under.

So a counselor who opts out and also works a salaried shift at an agency that bills Medicare has a conflict to settle before signing. Claims for services you personally furnish carry your NPI wherever they are filed from, and the affidavit says Medicare may not pay them 7Ref 7Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.420 — Beneficiary's agreement with the physician or practitioner not to bill Medicare.What the opt-out affidavit must contain and what it binds: the practitioner's NPI, or tax ID if none has been assigned, and the agreement to receive no direct or indirect Medicare payment during the period, including as an employee, under a reassignment of benefits, or as payment under a Medicare Advantage plan.. Ask the agency's billing lead how your NPI appears on their Medicare claims, and get the answer in writing, before you file anything.

Medicare Advantage sits inside the same clause, so opting out is not a decision about traditional Medicare alone 7Ref 7Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.420 — Beneficiary's agreement with the physician or practitioner not to bill Medicare.What the opt-out affidavit must contain and what it binds: the practitioner's NPI, or tax ID if none has been assigned, and the agreement to receive no direct or indirect Medicare payment during the period, including as an employee, under a reassignment of benefits, or as payment under a Medicare Advantage plan.. CMS notes separately that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. Whether your state's program does is a question for that Medicaid agency's provider enrollment page, since CMS says only that some may.

Doing neither, and how long it holds

Doing neither is a real position, and CMS states it plainly: practitioners who will not see Medicare patients are not required to enroll or to opt out 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. It costs nothing and it commits nothing. What it cannot do is absorb a single Medicare visit, because the moment you agree to see a beneficiary, one of the other two filings needed to be in place already.

Two things make that door narrower than it looks from inside a young caseload. The people most likely to move you through it are already on your schedule, and a long-standing client whose coverage changes mid-treatment does not become a new client. The question then arrives in the week you learn about it, with a session already booked.

The asymmetry is worth knowing before letting the question ride. Enrolling costs no application fee and can be done while the Medicare share of the practice is still small 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. Opting out mid-career, with a Medicare caseload already built, means every one of those patients signs a private contract or goes elsewhere 6Ref 6Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.415 — Terms of a private contract.The shape of the ongoing private-contract obligation an opt-out creates: a written contract signed by both parties, entered into for each two-year opt-out period, retained for the period, and not signed during emergency or urgent care..

Making the call this month

Three questions settle it, in order. Will Medicare beneficiaries be on your schedule in the next year? If no, file nothing and revisit when that changes 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. If yes, will you take the Medicare allowed amount as payment in full, set at 75 percent of the clinical psychologist rate 3Ref 3Office of the Federal Register (2026).42 CFR 414.53 — Fee schedule for clinical social worker, marriage and family therapist, and mental health counselor services..The payment rule that mental health counselor services are paid at 75 percent of the amount determined for clinical psychologist services under the physician fee schedule, and the fact that the regulation supplies no dollar amount, code or locality.? If yes, enroll. If no, opt out and take on the affidavit, the renewal calendar and a private contract for every Medicare patient 5Ref 5Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.410 — Opt-out.The opt-out timing conditions: the affidavit goes to each Medicare Administrative Contractor the practitioner would otherwise file claims with, a nonparticipating practitioner may opt out at any time, and the initial two-year period begins on the signature date only when the affidavit is filed within 10 days after the first private contract is signed.6Ref 6Centers for Medicare & Medicaid Services (Code of Federal Regulations) (2026).42 CFR § 405.415 — Terms of a private contract.The shape of the ongoing private-contract obligation an opt-out creates: a written contract signed by both parties, entered into for each two-year opt-out period, retained for the period, and not signed during emergency or urgent care..

The decision itself is yours and your accountant's, because the numbers that decide it are your own: the share of your referrals that arrive with a Medicare card, and what three-quarters of the clinical psychologist rate for your codes comes to against the fee you set for everyone else.

Whichever door you take, two dates belong on the calendar. If you opt out, the 30-day renewal notice deadline and the 90-day first-time cancellation window are yours to track, because nothing arrives to remind you 1Ref 1Centers for Medicare & Medicaid Services (2024).Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs).The January 1, 2024 start of Part B payment for mental health counselor services, the PECOS or paper CMS-855I route with no application fee, CMS's statement that a practitioner who will not see Medicare patients is required neither to enroll nor to opt out, the absence of a standard opt-out form, the automatic two-year renewal with its 30-day termination notice and its 90-day first-time cancellation window, and the note that opting out may disqualify a counselor from Medicare Advantage plans or from a state Medicaid program that requires Medicare enrollment first.. If you enroll, run the fee schedule look-up for your most-billed codes before the first Medicare visit, so the rate is a number you chose rather than one you meet on a remittance advice.