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Medicare Licensure Requirements

Medicare is a government-sponsored program that provides medical benefits to those without private insurance or the means to obtain care. Medicare is a single-payer health care program, which means that a segment of the population has its resources pooled into a fund that pays medical fees. Medicare is primarily created for those who cannot afford medical treatment. Medicare providers have to meet particular requirements to be licensed to accept Medicare recipients. Due to the shortage of primary care providers accepting Medicare patients, these providers might be required by law to accept Medicare patients to keep their medical licenses.

  1. Licensing

    • Before a physician may practice in Medicare, they must be certified. This requires that they first be a practicing physician. They must then submit a licensing form. Medicare providers can obtain Medicare licensing application forms from a Medicare carrier in the area. Physicians must agree to a non-discrimination standard. The Medicare provider must also agree to the reimbursement rates provided to them by Medicare. Medicare reimbursement rates are based on a rate schedule that is set by the federal government. The Medicare program pays 80 percent of the rate, while the patient pays 20 percent.

    Opting Out

    • Physicians who find that they cannot make a living with the fee schedule can choose to opt out of the program. They can then take Medicare patients on a case-by-case basis but they may only charge 95 percent of the fee schedule. Some physicians try to limit the number of Medicare patients that they treat since they cannot afford to keep practicing otherwise.

    Applications

    • A Medicare enrollment application must be filled out by a health care practitioner before he becomes licensed to provide Medicare. The Medicare provider will receive informational materials that must be read and signed, which include the Health Insurance Benefits agreement, the Civil Rights information form and the Medicare Intermediary Information form. Those practitioners who wish to work in Hospice care--a program focused on alleviating pain for patients suffering from terminal illnesses--must sign a Hospice Request for Certification in the Medicare Program form.

    Proposed Mandate

    • Since Medicare plans tend to have low reimbursement rates, primary care physicians are sometimes reluctant to visit with Medicare recipients. This results in a shortage of physicians. As a result, in 2010 legislation was proposed that requires physicians to provide care to patients receiving Medicare or risk losing their licenses.

    Unique Requirements

    • There are specific requirements for different areas of medicine. For example, to work as a physical therapist assistant under Medicare, the physical therapist assistant must have graduated from a two-year college program. The U.S. Public Health Service also requires that the physical therapist pass an exam administered by the agency.

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