DowncodedMedicare's Opt-Out List Is Mostly a Mental Health Directory Now
CMS published the August 2026 opt-out roster on September 16: 57,780 providers, and 61% of them are behavioral health. Two specialties that could not bill Medicare at all before January 2024 supplied 14,631 of the 25,394 names the file has added since, and almost a third of every marriage and family therapist Medicare holds a record for is on it.
You check the ordering provider before you bill the wheelchair, and the file behind that check has changed shape underneath you.
CMS publishes a monthly roster of every physician and practitioner who has opted out of Medicare entirely. The August 2026 vintage went up on September 16 and carries 57,780 rows.
Clinical psychologists, mental health counselors, clinical social workers, marriage and family therapists and psychiatrists account for 35,238 of them. That is 61.0% of the whole file.
Where 25,394 Names Came From
In December 2023 the same roster held 32,386 rows. Forty-five were marriage and family therapists and sixty-six were mental health counselors, 111 between them, because neither specialty could bill Medicare at all.
That ended on January 1, 2024.
CMS put it plainly: "Effective January 1, 2024, MFTs and MHCs can bill Medicare independently for their services furnished for the diagnosis and treatment of mental illnesses," paid at 75% of what a clinical psychologist earns on the fee schedule. Transmittal 12238 issued February 8 and stood up specialty codes E1 and E2 to carry them.
Twelve months later the roster held 48,702 rows, and those two specialties held 11,139.
So the file grew by 16,316 during 2024, and the two specialties Medicare had just started paying supplied 11,028 of that, or 67.6% (chart below). They are 14,742 today, a quarter of everyone on the list.
The effective dates inside the August file tell the same story from the other end. 15,737 rows carry a 2024 effective date, the largest cohort of any year on the roster, and 3,567 of them landed on 01/01/2024 exactly.
The benefit started and they opted out the same day.
One in Three
Set the opt-out roster against the enrollment file and the therapists stand apart.
Medicare's July 2026 public enrollment extract carries 14,907 marriage and family therapists enrolled as practitioners. Another 6,882 are on the opt-out roster, so 31.6% of every MFT CMS holds a record for has signed out of the program (chart below).
Nobody near them is close:
- Clinical psychologists, 17.9%, against 36,272 enrolled.
- Psychiatry, 12.1%.
- Mental health counselors, 10.3%, against 68,563 enrolled. The two specialties arrived on the same day and opt out at three times the rate.
- Clinical social workers, 7.2%, against 97,011 enrolled.
The mental health counselors took the benefit. The marriage and family therapists looked at 75% of the psychologist rate and a third of them declined.
What This Costs You
Almost none of these providers will ever appear on a claim you submit, because that is the point of opting out. They appear on your orders.
42 CFR 424.507 pays an ordered imaging study, lab service or DMEPOS item only where the ordering practitioner is "enrolled in Medicare in an approved status" or has "validly opted-out of the Medicare program." CMS says the same on its Ordering & Certifying page: "If you decide not to bill Medicare for your services, you can still order and certify by opting out of Medicare or enrolling solely to order and certify."
So opting out costs a provider nothing on the ordering side, in principle. In practice the opt-out file carries a column called Eligible to Order and Refer, and 27,484 of the 57,780 rows say N.
We took that column apart on August 26 and found 3,533 of the N rows sitting in the Order and Referring file anyway. On the August roster against the 09/24/2026 build it is 3,628, and 2,022 of them are marriage and family therapists or mental health counselors.
A month of drift, same shape, more of it.
Final Thoughts
These rows are sticky. Under 42 CFR 405.445 an opt-out runs in two-year periods that extend on their own unless the practitioner writes to every MAC at least 30 days before the current one ends, and 28,389 of today's rows already carry end dates in 2028.
Nothing here is a 2024 anomaly working its way through.
Congress paid for a behavioral health expansion and got two populations out of it. One enrolled, bills Medicare and shows up in your remittances.
The other took the license, took private payment, and kept a foot in your claims as the name on the order. Your referral master was built back when that second group was 111 people.
Thanks for reading.