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?
Answered by 11 licensed agents
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
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%.
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.
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
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.
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.
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.
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.
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.
