I’m a therapist who has opted out of Medicare. I have a client with BCBS-MA Medex. Can therapy be billed under this plan, and how can I do so without violating Medicare rules?

Question

Ann Sanfelippo · Accepted Answer

If you have formally opted out of Medicare, you cannot bill Medicare or any Medicare-covered services to Medicare Advantage or Medigap plans. BCBS-MA Medex is a Medicare Supplement, which means it only pays secondary to Medicare and generally requires the provider to be Medicare-eligible. Since you are opted out, therapy services that Medicare would normally cover are typically not payable by Medex. To stay compliant, you must bill the client as private pay.

Answered by Ann Sanfelippo on January 15, 2026

Broker Licensed in FL, AL, AZ & 14 other states

Answered by Ann Sanfelippo Medicare Insurance Agent

Voss Speros · Answer

Voss Speros here, Greek god of Medicare. If Medicare is all Greek to you, you're in luck, I'm Greek.

The question I got today is related to Medicare, but from a provider saying that they opted out of Medicare and now they've got a client with a Blue Cross Blue Shield Medicare supplement plan. They're wondering if they can bill the supplement plan because they've opted out of Medicare, and how can they do that without violating Medicare rules?

Here's the deal. The supplemental plan is a secondary plan that pays for what Medicare doesn't cover. Medicare covers 80%, and the supplement plan picks up the 20%.

So how can the provider bill for that? They have to bill private pay because they opted out of Medicare. If Medicare isn't going to pay for it, then the supplemental plan's not going to pay for the other side of it, because Medicare didn't pick up the 80%. And picking up the whole thing? No.

So if you're a provider and you opted out of Medicare for some reason, that means you can't bill it. It's a private pay bill at that point. So if that person can't afford it because they have this insurance, the supplemental insurance that covers everything, then you need to send them to somebody else and take the hit for that one. You know what? I'm sorry you didn't take Medicare, but Medicare supplement plans are good anywhere in the country with any doctor that takes Medicare. If they don't take Medicare, then no. Go find one that does. Literally, you could just go down the street and find somebody else.

But as a doctor or a provider, you need to let your patient know, hey, we can't bill that. So you need to find somebody else, or this person does it and it's okay.

I hope that answers the question, and we'll talk to you soon.

Ashley King · Answer

If you do not accept Medicare, the BCBS Massachusetts Medicare supplement plan will not pay for your services. The client will need to pay you directly and they will not allow any billing or reimbursement. The BCBS-MA Medex covers therapy for providers who accept original Medicare.

Answered by Ashley King on January 19, 2026

Broker Licensed in MD, AL, AR & 9 other states

Answered by Ashley King Medicare Insurance Agent

Mark Bilgere · Answer

If the client has BCBS-MA Medex which is a supplement, there is not a way to bill this. Since you have opted out of Medicare, there is no Medicare payment of the 80%. Since Medicare will not pay the 80% then BCBS-MA Medex will not pay the 20%.

Answered by Mark Bilgere on January 15, 2026

Broker Licensed in TX, AR, IN & LA, MN, NE & OK

Answered by Mark Bilgere Medicare Insurance Agent

Wendy Lollar · Answer

This isn’t something that I’m very familiar with but what I’ve found is if this is truly Medex (Medigap) and you’re opted out, you generally cannot bill Medex for therapy in a way that results in payment for Medicare-covered Part B therapy services. 
I would recommend you reaching out to the carrier to verify rules and compliance.

Niels Heemskerk · Answer

Hi, If you are a provider not accepting Medicare, it will not be possible to bill them. Your client will have to pay out of pocket, or you need to get back in line with Medicare. The best place for you to ask this question is directly with Medicare.

Answered by Niels Heemskerk on July 27, 2026

Agent Licensed in IL, MI, OH, PA, TX & WI

Answered by Niels Heemskerk Medicare Insurance Agent

Bill Wheeler · Answer

No, therapy cannot be billed to Blue Cross Blue Shield of Massachusetts (BCBS-MA) Medex under this arrangement, and attempting to do so could result in a Medicare compliance violation. Because you have officially opted out of Medicare, the service must be handled strictly as an out-of-pocket private contract

Answered by Bill Wheeler on May 18, 2026

Broker Licensed in KY & IN

Answered by Bill Wheeler Medicare Insurance Agent

Christine Brewer · Answer

Yes, BCBS-MA Medex is a Medicare Advantage plan, so services are still governed by Medicare rules, even though it’s run by a private insurer. If you have formally opted out of Medicare, you generally cannot bill a Medicare Advantage plan for covered services; instead, you would need a private-pay agreement with the client and ensure you are not submitting any claims or receiving reimbursement tied to Medicare.

Answered by Christine Brewer on January 19, 2026

Broker Licensed in FL

Answered by Christine Brewer Medicare Insurance Agent

Maggie Flynn · Answer

I would contact the plan directly and ask these questions. Normally, I tell my customers if a doctor or therapist is not contracted with Medicare, the full cost of the service is their responsibility. I wonder if you would reconsider being contracted with Medicare?

Answered by Maggie Flynn on July 21, 2026

Broker Licensed in NY, CT, DE, FL, NJ & PA

Answered by Maggie Flynn Medicare Insurance Agent

William Wheatley · Answer

Will tell you to contact your states MAC Medicare Administrator Contractor for clarification because States can vary. As far as I know you cannot bill BCBS MA MEDIX because it is a medicare supplemental insurance and you opted out of all medicare which usually lasts two years before being allowed to opt in again. Again each state is different so call your states MAC in your state to verify this.

Answered by William Wheatley on January 19, 2026

Agent Licensed in MD

Answered by William Wheatley Medicare Insurance Agent

Mike Alexander · Answer

If you have opted out of medicare the plan will no longer pay, unless you are in the Medicare payment system the patient will need to pay you as Medicare will not

Roger Werking · Answer

If y

If you have opted out of Medicare, you cannot bill Medicare Advantage Plans.
Once opted out, you may not be paid by medicare or medicars advantage plan for services under part B

Tamekia Mckinnie · Answer

Anything that is medically necessary is covered by Medicare. If you’d like to be a provider, then you would contract with the carriers and be added to their network, then you be eligible for standardized payments according to that carriers payment structure.

Answered by Tamekia Mckinnie on June 8, 2026

Agent Licensed in FL

Answered by Tamekia Mckinnie Medicare Insurance Agent

Adam Ernst · Answer

The best thing to do is to call the agent in charge of this client. They will be able to answer their questions the best, as they can connect the client with BCBS. The location of the client and what is covered plays a big part in what is covered. Is it in network or out of network? If not agent is on the account, ask to speak to a local agent in the area. We, as agents, love helping people and creating better and more trustworthy business. We are here to help. Please use us as it is no cost to speak to somebody locally.

Answered by Adam Ernst on January 15, 2026

Agent Licensed in NC, SC & TN

Answered by Adam Ernst Medicare Insurance Agent

Leonie Dawkins · Answer

The member would  call member services for her plan carrier, and ask this question; If therapist services are covered by that carrier

Kayla Thola · Answer

I’d suggest checking directly with BCBS-MA Medex to confirm how coverage may apply in this situation and reviewing CMS guidance before moving forward.

Edward MacConnell · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/billing-therapy-bcbs-medex-medicare-opt-out#edward-macconnell

I’m a therapist who has opted out of Medicare. I have a client with BCBS-MA Medex. Can therapy be billed under this plan, and how can I do so without violating Medicare rules?

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I’m a therapist who has opted out of Medicare. I have a client with BCBS-MA Medex. Can therapy be billed under this plan, and how can I do so without violating Medicare rules?

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