Medicare Provider Participation Open Enrollment

The annual Medicare participation open enrollment period begins on November 15 and ends on December 31. This article will describe the differences between participating and non-participating suppliers and explain how to change your participation status for 2025.

What You Need to Know

Medicare DMEPOS suppliers can choose to be either a participating or non-participating provider. Participating providers agree to accept assignment on all claims for Medicare products and services. They agree to accept the Medicare-allowed amount as payment in full and will collect any unmet deductible and 20% coinsurance from the beneficiary. In comparison, non-participating providers may accept assignment on a claim-by-claim basis. If a non-participating provider does not accept assignment, they can charge more than the Medicare allowable and will collect directly from the patient. In this instance, the supplier is required to file the claim with Medicare on a non-assigned basis on behalf of the patient, and any Medicare reimbursement is sent directly to the patient.

Both participating and non-participating providers are required to follow Medicare coverage policies. An ABN is required for assigned and non-assigned claims when the supplier reasonably expects that Medicare will not pay for the item or service, which is otherwise usually covered by Medicare. If a non-assigned claim is reviewed and payment is denied by Medicare, the supplier will be required to refund the amount collected back to the Medicare beneficiary unless a valid ABN was obtained. Because non-participating providers are considered "out of network," beneficiaries are more likely to choose an "in network," participating provider to avoid increased costs and paying out of pocket.

What this Means for You

If you do not want to change your participation status, then there is nothing you need to do during the enrollment period. However, if you do want to change your status, then you need to complete one of the following:

• Switching from non-participating to participating supplier: complete the Medicare Participating Physician or Supplier Agreement (CMS-460) and mail a copy to each Medicare Administrative Contractor (MAC) that you’ll send Part B DMEPOS claims to. This form must be postmarked before December 31, 2024.
• Switching from participating to non-participating supplier: write to each MAC that you send Part B DMEPOS claims to tell them that you don’t want to participate effective January 1, 2025. This written notice must be postmarked before December 31, 2024.

During this time, you should also log into PECOS and review the correspondence address listed for your company to ensure it is correct. The National Provider Enrollment contractors will send out a postcard within the next couple of weeks reminding you of the participation open enrollment period. If your postcard is returned to the sender, the NPE contractor will audit your provider enrollment record. An incorrect address may result in a revocation for not reporting changes in information within 30 days, as required by the DMEPOS supplier standards.

For more information, review the Annual Medicare Participation Announcement from CMS and Noridian's article on Assignment and Non-Assignment of Benefits.