Medicare and Out-of-Network Psychiatrists: What You Can and Cannot Claim

With Original Medicare, what you can claim for a psychiatrist's visit depends on the psychiatrist's status with Medicare, not on a network. A participating provider bills Medicare for you, a non-participating provider should still submit a claim for covered services, and a provider who has opted out of Medicare cannot be paid by Medicare at all, except in emergencies, even for services Medicare would normally cover. Before a first visit with any psychiatrist who is "out of network" for Medicare, ask which of the three applies.

Medicare Advantage plans add a second layer, because their networks and out-of-network rules vary by plan type. This guide explains the three provider categories, what a private contract means, how Medicare Advantage handles out-of-network care, and when you can file your own claim. It is general information, not tax or legal advice.

What Medicare covers for outpatient mental health

Medicare Part B covers a wide range of outpatient mental health services, including psychiatric evaluation, medication management, and individual and group psychotherapy. Covered visits can be with psychiatrists and other doctors, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, physician assistants, marriage and family therapists, and mental health counselors. After you meet the Part B deductible, you generally pay 20% of the Medicare-approved amount for visits to diagnose or treat your condition.

That coverage applies only when the clinician's services can be billed to Medicare. Whether they can is the question the rest of this guide answers.

Participating, non-participating and opted-out providers

The limiting charge protects you only with non-participating providers who remain in Medicare. It does not apply to a physician who has properly opted out, except for emergency or urgent care.

What opting out means

A physician or another eligible practitioner can choose to leave Medicare's billing system entirely. The federal opt-out rules apply to physicians and to practitioners including nurse practitioners, physician assistants, clinical nurse specialists, clinical psychologists, clinical social workers, marriage and family therapists and mental health counselors. So the question applies to every member of a mental health team, not just the psychiatrist.

Opt-out is not a short-term choice. An opt-out period lasts two years from the date the affidavit is signed and continues for each successive two-year period unless the clinician properly cancels it. Medicare.gov describes the minimum as 2 years.

During the opt-out period, neither Medicare nor any Medicare Advantage plan may pay the clinician for services, except for emergency or urgent care handled under special rules. The clinician is prohibited from submitting claims to Medicare for your care, and you agree in the private contract not to submit them either.

Prescriptions and lab orders from an opted-out clinician

Opting out does not stop a clinician from prescribing. A clinician who has opted out, and who has not been excluded from Medicare or had enrollment revoked, may still order, certify, prescribe or refer you for Medicare-covered items, services and drugs, as long as the clinician is not paid by Medicare for doing so. In practice, your pharmacy benefit or a laboratory that bills Medicare can treat those orders under its own coverage rules. Ask your Part D plan about any medication restrictions, and see lowering prescription costs for psychiatric medications for other levers.

The private contract: what it must say

If a clinician has opted out, you will be asked to sign a private contract before receiving care. Federal rules spell out its required terms, so you can check a contract against them.

Emergencies follow a different rule. An opted-out clinician who provides emergency or urgent care to a Medicare patient without an existing private contract must submit a claim to Medicare and can collect no more than the limiting charge if a physician, or the deductible and coinsurance if another practitioner. For where to go in a psychiatric emergency in New York City, see psychiatric emergency or urgent need.

Medicare Advantage and out-of-network psychiatrists

Medicare Advantage plans run their own networks, and the plan type sets the out-of-network rules.

• PPO plans generally let you use out-of-network providers for covered services, but you will usually pay more, and Medicare.gov describes those providers as ones participating in Medicare or accepting assignment. Medicare.gov advises contacting the PPO before getting services from an out-of-network provider to confirm the services are medically necessary and covered.
• HMO plans may leave you paying the full cost of care outside the plan's network. An HMO with a point-of-service option may cover some out-of-network services at a higher copayment or coinsurance.
• No Medicare Advantage plan may pay a clinician who has opted out of Medicare, except under the emergency and urgent care rules.

Some Medicare Advantage plans are sold by commercial insurers that also sell employer plans. Their Medicare plans follow Medicare Advantage rules, not the employer-plan rules described in the guides to UnitedHealthcare or other insurers, so call the plan directly. Ask three things: whether your plan covers out-of-network outpatient mental health visits, what your share would be, and whether the clinician's Medicare status allows the plan to pay them at all.

Filing your own Medicare claim

When a clinician has not opted out but does not file for you, you can file yourself. Medicare claims must be filed no later than 12 months after the date of service, unless an exception applies. The form is the Patient Request for Medical Payment, form CMS-1490S. Medicare.gov says to send the completed form, the itemized bill from the provider, a letter explaining why you are submitting the claim yourself, and any supporting documents such as the doctor's notes.

1. Confirm the clinician has not opted out. A superbill from an opted-out clinician cannot be submitted to Medicare.
2. Ask the clinician to submit the claim first; a non-participating provider should submit claims for covered services.
3. If they decline, complete the claim form and attach the itemized bill and your letter.
4. Keep copies, and note the 12-month deadline for each date of service.

The superbill items that commercial insurers expect, and how to track claims, are covered in superbills and out-of-network claims.

How to find out where a clinician stands

Ask directly, in these words: "Do you participate in Medicare, are you non-participating, or have you opted out? Does that apply to every clinician I might see in your practice?" Then check. Medicare.gov's page on whether a provider accepts Medicare links to a lookup of providers who have opted out. If the answer is opt-out, ask to see the private contract before your first visit, and compare it with the table above.

The answer may differ across a team. A psychiatrist, a nurse practitioner and a therapist in the same practice can each have a different Medicare status, because opt-out is an individual choice. More questions worth asking before you book are in questions to ask on a psychiatry discovery call.

Common mistakes

• Assuming "out of network" works the same way as with an employer plan. In Original Medicare the clinician's participation, non-participation or opt-out status is what decides payment.
• Signing a private contract at the front desk without reading it. You are entitled to a copy before services, and it should state the opt-out period dates.
• Sending a superbill from an opted-out clinician to Medicare or a Medigap insurer. The contract you signed says neither will pay.
• Letting claims pile up. A claim filed more than 12 months after the date of service is generally refused.
• Assuming a Medicare Advantage PPO will pay an opted-out clinician. The opt-out rules bar payment by Medicare Advantage plans too.
• Assuming one clinician's status covers a whole practice. Each clinician makes the opt-out choice individually.

Weighing the options

Paying privately can still make sense for some people, for example when they want longer visits or a particular clinician, and a written estimate helps; see good faith estimates for self-pay psychiatry. When cost is the main concern, care that bills Medicare is usually the better first step. Families arranging care for an older parent may also find psychiatric care for an aging parent useful, and people with both Medicare and Medicaid should read Medicaid and private-pay psychiatry.

How Dr. Lewis's practice handles Medicare

Dr. Lewis is an out-of-network provider with all insurance plans, including Medicare and Medicaid, as are all of the practice's practitioners, and payment is due at the time of service. Before booking, ask the team directly about each clinician's Medicare status and whether any Medicare claim can be filed for their services; the free discovery call covers care options, scheduling and insurance questions. The practice offers a Good Faith Estimate of expected costs before starting care, and lab and supplement costs are separate from visit fees. Fees are listed on the insurance and payment page, and billing questions are covered in the practice's frequently asked questions. If you need care that is in network with your plan, ask the team on the discovery call about options. The rest of the cost and insurance series is in the Choosing Psychiatric Care guide.

Frequently asked questions

Can I submit a superbill to Medicare after seeing an out-of-network psychiatrist?

Only if the psychiatrist has not opted out of Medicare. If they participate or are non-participating, Medicare claims can be filed for covered services. If they have opted out and you signed a private contract, you agreed not to submit claims and Medicare will not pay.

Will my Medigap policy pay for an opted-out psychiatrist?

No. Federal rules require the private contract to tell you that Medigap plans do not pay for services Medicare does not pay for, and other supplemental plans may also decline.

Does signing a private contract affect my other Medicare coverage?

No. The contract covers only that clinician's services. You keep your right to Medicare-covered care from any clinician who has not opted out.

Can an opted-out psychiatrist's prescriptions be covered by my Part D plan?

Federal rules allow an opted-out clinician who is not excluded from Medicare to prescribe Medicare-covered drugs. Your Part D plan's own formulary and rules still apply, so check with the plan.

What if I see a psychiatrist by telehealth?

The same Medicare status questions apply. Telehealth coverage rules can change, so ask Medicare or your plan about current coverage before relying on it.

Does an out-of-network psychiatrist have to tell me they opted out?

An opted-out clinician must use a written private contract, signed before services, that states Medicare will not pay. If you have not been offered one, ask about the clinician's Medicare status before your visit.

Sources

1. Does your provider accept Medicare as full payment?. Medicare.gov (CMS), 2026. medicare.gov
2. 42 CFR Part 405 Subpart D, Private Contracts (sections 405.400-405.455). Electronic Code of Federal Regulations, 2026. ecfr.gov
3. Mental health care (outpatient). Medicare.gov (CMS), 2026. medicare.gov
4. Filing a claim. Medicare.gov (CMS), 2026. medicare.gov
5. Preferred Provider Organizations (PPOs). Medicare.gov (CMS), 2026. medicare.gov
6. Health Maintenance Organizations (HMOs). Medicare.gov (CMS), 2026. medicare.gov

Educational information, not medical, tax or legal advice. Decisions about diagnosis, medication and treatment belong with a clinician who knows your history.