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What Does It Mean to be Medicare Certified?

Medicare does not pay for services you receive from healthcare providers that are not Medicare certified. Providers can go through the process to become certified and bill Medicare for their services. According to the nonprofit KFF, there were 6,200 Medicare certified hospitals in the United States as of 2021. KFF also notes that there were 10,441 federally qualified health centers that were Medicare certified in 2021. It's important to make sure any services and treatments you receive are from a Medicare certified provider. What is Medicare certification? When a provider is Medicare certified, it means they agree to offer services at a quality level approved by Medicare. Medicare only pays for services and treatments that are provided by hospitals that voluntarily seek certification and receive approval from the Centers for Medicare & Medicaid Services (CMS). The Department of Health contracts with CMS to evaluate facilities' compliance with federal regulations. They use periodic on-site surveys for these evaluations. How do providers become Medicare certified? Each state may have a slightly different certification process. But the process always ends with the CMS, where a provider receives approval. State Survey Agencies Each process will include an initial assessment by a State Survey Agency. These are the agencies that perform periodic surveys of Medicare certified providers. The State Survey Agencies act on behalf of the CMS to perform these assessments under the agreements in Section 1864 of the Social Security Act (the Act). The state agencies do not have Medicare determination-making functions. These authorities are delegated to CMS regional offices. Process The acts that the State Survey Agencies perform for the CMS are referred to as 'the certification process.' This process includes: Identifying potential participants: The law guarantees Medicare beneficiaries that payment will only be made for health services provided by or furnished in entities that meet the requirements of the Act. Conducting fact-finding surveys and investigations: This may be referred to as 'the survey process.' It includes verifying how well the providers are complying with the conditions of participation (CoPs). Certifying and recertifying: Certifications are sent periodically to state or federal agencies regarding whether providers are qualified to participate in programs like Medicare. Explaining requirements: State agencies have the responsibility to advise providers and potential providers about applicable Federal regulations that enable them to participate in programs, such as Medicare. These agencies also advise the providers on maintaining the standard of healthcare consistent with the CoPs and conditions for coverage (CfCs). How do I find a Medicare certified provider? It's important to receive treatment from a Medicare certified provider. This is the only way Medicare will cover the services you receive. You can find the following types of providers near you using the Medicare search tool: hospitals doctors and clinicians nursing homes and rehab services hospice care inpatient rehabilitation facilities home health services long-term care hospitals dialysis facilities medical equipment and suppliers If you have Medicare Advantage, your insurer will typically have a list of in-network providers you can use. Summary A Medicare certified provider agrees to provide services that are of the quality approved by Medicare. Medicare will only cover services and treatments from certified providers. You can find providers near you using the Medicare search tool. Or if you have Medicare Advantage, your insurer can provide you with a list of in-network providers. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.