{ "study": { "slug": "medicare-opt-out-behavioral-health-2026", "title": "Who opts out of Medicare: a behavioral-health story, 2026", "standfirst": "Of the 56,117 clinicians on CMS's Medicare opt-out list, 60.9% belong to five behavioral-health specialties — psychologists, social workers, mental health counselors, marriage-and-family therapists, and psychiatrists. The largest single year was 2024, when 15,978 opted out, two-thirds of them therapists Congress had just made Medicare-eligible.", "desk": "access", "article_type": "Original Research", "published": "2026-06-15", "issue": 75, "doi": "10.5072/fonteum/medicare-opt-out-behavioral-health-2026", "url": "https://fonteum.com/research/medicare-opt-out-behavioral-health-2026", "methodology_version": "cms-opt-out/v1" }, "data_as_of": "2026-06-15", "datasets": [ { "slug": "cms-provider-data-catalog", "name": "CMS Provider Data Catalog", "publisher": "CMS — Provider Data Catalog", "upstream_url": null } ], "key_findings": [ { "number": "60.9%", "finding": "of the 56,117 clinicians on CMS's Medicare opt-out list belong to five behavioral-health specialties — clinical psychologist, clinical social worker, mental health counselor, marriage-and-family therapist, and psychiatry. They take all five of the top five slots; no other specialty exceeds 8%", "dataset": "cms-provider-data-catalog" }, { "number": "15,978", "finding": "clinicians took effect as Medicare opt-outs in 2024 — five times the 2023 figure of 3,190 and the largest single year on the list. 14,192 of them (88.8%) were behavioral-health providers", "dataset": "cms-provider-data-catalog" }, { "number": "10,844", "finding": "of the 2024 opt-outs (67.9%) were marriage-and-family therapists or mental health counselors — the two professions Congress first allowed to bill Medicare effective January 1, 2024 under the Consolidated Appropriations Act, 2023. They became eligible and filed to opt back out the same year", "dataset": "cms-provider-data-catalog" }, { "number": "19.1%", "finding": "of the national opt-out list sits in California, the most of any state; 76.8% of California's opt-outs are behavioral-health providers. Massachusetts has the highest behavioral share (81.7%), Florida among the large states the lowest (36.2%)", "dataset": "cms-provider-data-catalog" }, { "number": "56,117", "finding": "opt-out affidavits across 116 specialties make up the published file, snapshot dated 2026-05-15; 55,568 distinct NPIs, none missing in this snapshot. Every figure is a count over published records — no individual clinician is named, ranked, or scored", "dataset": "cms-provider-data-catalog" } ], "faqs": [ { "q": "What does it mean for a doctor to 'opt out' of Medicare?", "a": "Opting out means a clinician has filed a sworn affidavit with CMS agreeing to treat Medicare patients only under a private contract. For those services neither the clinician nor the patient may submit a Medicare claim; the patient pays out of pocket. The election runs two years and, since 2015, renews automatically unless the clinician cancels it." }, { "q": "Which providers opt out of Medicare the most?", "a": "Behavioral-health providers. Five specialties — clinical psychologist, clinical social worker, mental health counselor, marriage-and-family therapist, and psychiatry — hold 34,155 of the 56,117 affidavits on CMS's opt-out list, or 60.9%, and occupy all five top slots. Dentists and oral surgeons are the next-largest block at 15.7%." }, { "q": "Why did so many therapists opt out in 2024?", "a": "Because 2024 was the first year they could enroll. The Consolidated Appropriations Act, 2023 let marriage-and-family therapists and mental health counselors bill Medicare starting January 1, 2024. Of the 15,978 clinicians who opted out that year, 10,844 (67.9%) were from those two professions — newly eligible providers who enrolled and immediately filed to opt back out." }, { "q": "Does opting out mean a provider did something wrong?", "a": "No. An opt-out affidavit is an enrollment election, not a disciplinary or quality signal. It records one business decision — to contract privately with patients rather than bill Medicare — and is entirely separate from exclusion, sanction, or any assessment of a clinician's competence or conduct. This study draws no inference about any provider." }, { "q": "Which states have the most Medicare opt-outs?", "a": "California leads with 10,723 affidavits, 19.1% of the national file, followed by New York (4,822) and Texas (3,477). The behavioral-health share varies sharply by state: 81.7% of Massachusetts opt-outs are behavioral-health providers and 76.8% of California's, against 36.2% in Florida, where dentists and physicians weigh more heavily." }, { "q": "Can a provider who opted out still order and refer Medicare services?", "a": "Often, yes — opting out of billing is separate from the right to order and refer. But that right is tied to provider type: physicians and most non-physician practitioners keep it, while psychologists, social workers, counselors, and therapists generally cannot order and refer at all. That is why 84.6% of dental opt-outs are order/refer-eligible against only 32.5% of behavioral-health ones." }, { "q": "Can I reproduce these figures?", "a": "Yes. Every number is a direct count over the public cms_opt_out_affidavits table — CMS's Opt Out Affidavits file, snapshot dated 2026-05-15 — with no modeling. The exact SQL for the specialty mix, the year-by-year effective dates, the state breakdown, and the order/refer split is published in the reproducibility block below." } ], "citation": { "apa": "Fonteum Research. (2026, June 15). Who opts out of Medicare: a behavioral-health story, 2026. Fonteum Research, Issue 75. https://doi.org/10.5072/fonteum/medicare-opt-out-behavioral-health-2026", "url": "https://fonteum.com/research/medicare-opt-out-behavioral-health-2026" }, "reproducible_sql": "-- Who opts OUT of Medicare — and why it is overwhelmingly a behavioral-health\n-- story. Fully reproducible query.\n--\n-- Question: of the clinicians who have filed a formal affidavit OPTING OUT of\n-- Medicare (agreeing to treat Medicare patients only under private contract,\n-- where neither the clinician nor the patient may bill Medicare for the care),\n-- what kind of provider are they, where are they, and when did they opt out?\n-- The lead figure: 34,155 of the 56,117 affidavits on CMS's published opt-out\n-- list — 60.9% — are held by five behavioral-health specialties (clinical\n-- psychologist, clinical social worker, mental health counselor, marriage &\n-- family therapist, psychiatry). Opting out is a coverage signal, NOT a\n-- quality, fraud, or wrongdoing signal of any kind.\n--\n-- Source:\n-- public.cms_opt_out_affidavits — CMS \"Opt Out Affidavits\" public-use file,\n-- published monthly via the CMS data catalog (data.cms.gov, dataset\n-- 9887a515-…). 56,117 affidavit rows; snapshot last_updated 2026-05-15.\n-- Public, read-only. License: US-Government-Works (17 U.S.C. Sec. 105).\n-- methodology_version = 'cms-opt-out/v1'.\n--\n-- Universe: this study reads the published file AS A WHOLE — every row is a\n-- clinician CMS lists as having a Medicare opt-out affidavit in effect. The\n-- file is the point-in-time snapshot (last_updated 2026-05-15); figures are\n-- not modeled as a trend. CMS removes affidavits once withdrawn, so the file\n-- is the current opt-out roster, not a cumulative history.\n--\n-- Counting note: an affidavit carries an effective date and a 2-year end date\n-- (since 2015 affidavits auto-renew unless the clinician cancels), so the\n-- effective-date YEAR below is the year a clinician FIRST opted out, not a\n-- yearly flow of net new opt-outs. 55,568 distinct NPIs across 56,117 rows.\n-- No row in this snapshot has a NULL NPI. No individual is named in the study.\n\n-- ============================================================================\n-- (1) Universe reconciliation — the published file at a glance.\n-- ============================================================================\nSELECT\n count(*) AS affidavits,\n count(DISTINCT npi) AS distinct_npi,\n count(DISTINCT specialty) AS specialties,\n count(*) FILTER (WHERE npi IS NULL OR npi = '') AS null_npi,\n min(optout_effective_date) AS earliest_effective,\n max(optout_effective_date) AS latest_effective,\n max(last_updated) AS snapshot\nFROM public.cms_opt_out_affidavits;\n-- affidavits 56,117 · distinct_npi 55,568 · specialties 116 · null_npi 0\n-- earliest_effective 1998-01-01 · latest_effective 2026-07-01 · snapshot 2026-05-15\n\n-- ============================================================================\n-- (2) HEADLINE: opt-out by specialty, top 12. Five behavioral-health\n-- specialties take the top five slots and 60.9% of the whole file.\n-- ============================================================================\nSELECT\n specialty,\n count(*) AS affidavits,\n round(100.0 * count(*) / sum(count(*)) OVER (), 1) AS pct_of_all\nFROM public.cms_opt_out_affidavits\nGROUP BY specialty\nORDER BY affidavits DESC\nLIMIT 12;\n-- Clinical Psychologist 7,730 13.8%\n-- Mental Health Counselor 7,507 13.4%\n-- Clinical Social Worker 7,311 13.0%\n-- Marriage And Family Therapist 6,633 11.8%\n-- Psychiatry 4,974 8.9%\n-- Dentist 4,464 8.0%\n-- Oral Surgery 3,942 7.0%\n-- Family Practice 2,808 5.0%\n-- Nurse Practitioner 2,685 4.8%\n-- Internal Medicine 1,710 3.0%\n-- Obstetrics/Gynecology 766 1.4%\n-- Physician Assistant 670 1.2%\n\n-- ============================================================================\n-- (3) The behavioral-health share, computed directly. The five specialties in\n-- (2) are aggregated into one group; dental (dentist + oral/maxillofacial\n-- surgery) is the second-largest block.\n-- ============================================================================\nSELECT\n count(*) FILTER (WHERE specialty IN (\n 'Clinical Psychologist','Clinical Social Worker','Mental Health Counselor',\n 'Marriage And Family Therapist','Psychiatry')) AS behavioral,\n round(100.0 * count(*) FILTER (WHERE specialty IN (\n 'Clinical Psychologist','Clinical Social Worker','Mental Health Counselor',\n 'Marriage And Family Therapist','Psychiatry')) / count(*), 1) AS behavioral_pct,\n count(*) FILTER (WHERE specialty IN (\n 'Dentist','Oral Surgery','Maxillofacial Surgery')) AS dental,\n round(100.0 * count(*) FILTER (WHERE specialty IN (\n 'Dentist','Oral Surgery','Maxillofacial Surgery')) / count(*), 1) AS dental_pct\nFROM public.cms_opt_out_affidavits;\n-- behavioral 34,155 · behavioral_pct 60.9% · dental 8,823 · dental_pct 15.7%\n-- (behavioral + dental together = 76.6% of every opt-out affidavit on file.)\n\n-- ============================================================================\n-- (4) WHEN they opted out — first-opt-out year, 2018 onward. 2024 is a step\n-- change: 15,978 affidavits take effect, 5x the 2023 count (3,190), and\n-- 10,844 of the 2024 cohort (67.9%) are marriage & family therapists or\n-- mental health counselors — the two specialties Congress first allowed to\n-- bill Medicare effective 2024-01-01 (Consolidated Appropriations Act, 2023).\n-- They became eligible to enroll and immediately filed to opt back out.\n-- ============================================================================\nSELECT\n extract(year FROM optout_effective_date)::int AS effective_year,\n count(*) AS affidavits,\n count(*) FILTER (WHERE specialty IN (\n 'Marriage And Family Therapist','Mental Health Counselor')) AS mft_and_mhc,\n count(*) FILTER (WHERE specialty IN (\n 'Clinical Psychologist','Clinical Social Worker','Mental Health Counselor',\n 'Marriage And Family Therapist','Psychiatry')) AS behavioral\nFROM public.cms_opt_out_affidavits\nWHERE optout_effective_date >= '2018-01-01'\nGROUP BY effective_year\nORDER BY effective_year;\n-- 2018 2,312 2 1,197\n-- 2019 2,260 0 1,218\n-- 2020 1,680 0 798\n-- 2021 2,023 0 981\n-- 2022 2,449 0 1,145\n-- 2023 3,190 24 1,777\n-- 2024 15,978 10,844 14,192 <- the spike: 88.8% behavioral, 67.9% MFT/MHC\n-- 2025 6,770 2,588 4,772\n-- 2026 2,310 682 1,436 (partial year)\n\n-- ============================================================================\n-- (5) WHERE they are — top 10 states by affidavit count, with each state's\n-- own behavioral-health share. California alone holds 19.1% of the national\n-- opt-out file; Massachusetts has the highest behavioral share (81.7%),\n-- Florida the lowest of the large states (36.2%, a more dental/physician mix).\n-- ============================================================================\nSELECT\n state_code,\n count(*) AS affidavits,\n round(100.0 * count(*) / sum(count(*)) OVER (), 1) AS pct_of_all,\n round(100.0 * count(*) FILTER (WHERE specialty IN (\n 'Clinical Psychologist','Clinical Social Worker','Mental Health Counselor',\n 'Marriage And Family Therapist','Psychiatry')) / count(*), 1) AS behavioral_pct\nFROM public.cms_opt_out_affidavits\nWHERE state_code IS NOT NULL\nGROUP BY state_code\nORDER BY affidavits DESC\nLIMIT 10;\n-- CA 10,723 19.1% bh 76.8% · NY 4,822 8.6% bh 65.7% · TX 3,477 6.2% bh 49.4%\n-- WA 2,780 5.0% bh 70.2% · FL 2,716 4.8% bh 36.2% · IL 2,122 3.8% bh 58.1%\n-- MA 2,081 3.7% bh 81.7% · NC 1,920 3.4% bh 62.7% · VA 1,884 3.4% bh 57.7%\n-- MD 1,852 3.3% bh 70.6%\n\n-- ============================================================================\n-- (6) Order/refer eligibility by group. Opting out of billing does NOT strip a\n-- clinician of the separate right to ORDER and REFER Medicare services —\n-- but that right is tied to provider TYPE. Physicians and most NPPs keep it;\n-- psychologists, social workers, counselors and MFTs generally cannot order\n-- and refer at all, which is why the behavioral group's eligibility is low.\n-- This is a structural artifact of provider role, not a behavioral choice.\n-- ============================================================================\nWITH g AS (\n SELECT\n CASE\n WHEN specialty IN ('Clinical Psychologist','Clinical Social Worker',\n 'Mental Health Counselor','Marriage And Family Therapist','Psychiatry')\n THEN 'behavioral'\n WHEN specialty IN ('Dentist','Oral Surgery','Maxillofacial Surgery')\n THEN 'dental'\n ELSE 'other'\n END AS grp,\n eligible_to_order_and_refer AS e\n FROM public.cms_opt_out_affidavits\n)\nSELECT\n grp,\n count(*) AS affidavits,\n count(*) FILTER (WHERE e) AS order_refer_eligible,\n round(100.0 * count(*) FILTER (WHERE e) / count(*), 1) AS eligible_pct\nFROM g\nGROUP BY grp\nORDER BY affidavits DESC;\n-- behavioral 34,155 · 11,106 eligible · 32.5%\n-- other 13,139 · 11,166 eligible · 85.0%\n-- dental 8,823 · 7,461 eligible · 84.6%", "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)", "generated_by": "Fonteum — https://fonteum.com", "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included." }