Deadline to opt in/out as Medicare provider

By Ann Milar, CDA dental benefits analyst

Note: The Medicare Part D enrollment deadline was extended again. Please see "Medicare Part D enrollment deadline now January 2019” for more details.

Traditional Medicare doesn't cover most dental services. In fact, Medicare will currently only pay for dental services that are an integral part of either a covered procedure (e.g., reconstruction of the jaw following accidental injury) or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Medicare will also make payment for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances.

Despite the limited instances when Medicare may pay for dental treatment, there are two important reasons why dentists need to pay attention to upcoming changes and understand the potential impact to dental patients and one's dental practice.

First, with 35,000 licensed dentists in California and more than 5 million Californians enrolled in Medicare (according to 2012 Centers for Medicare and Medicaid Services (CMS) statistics), simple arithmetic shows that there are 143 Medicare patients per dentist in the state. That is a lot of potential patients who may be impacted with the upcoming Medicare changes.

Secondly, CMS issued a recent rule requiring all physicians and eligible professionals — including dentists — who prescribe Part D-covered drugs to be enrolled in Medicare or opt out for those prescriptions to be covered under Part D by June 1, 2015.

What exactly does this mean for dentists and their dental practices?

This means that if you have Medicare-eligible patients for whom you prescribe medication, or perform biopsies that require sending the patient's sample to a pathologist, or need to refer the patient to a specialist, you'll need to do one of the following:

1. Enroll as a Medicare provider

Dentists wishing to enroll as Medicare providers must accept assignment on all Medicare claims and accept Medicare-approved payment in full. A dentist choosing to be a participating provider with Medicare must enroll either through the completion and submission of the CMS-855S form or by submitting their enrollment electronically through the Provider Enrollment, Chain and Ownership System (also known as PECOS).

2. Opt Out of Medicare

Dentists may elect to opt out of the Medicare Program by privately contracting with Medicare-eligible patients utilizing a Private Contract Form. When a dentist opts out of Medicare, the dentist cannot receive Medicare payments for a two-year period. Dentists choosing to opt out of Medicare and bill patients privately must complete the Medicare Opt-Out Affidavit and send it to Noridian at the applicable address below:

Noridian JE Part B — Northern CA Enrollment
PO Box 6774
Fargo ND 58108-6774

Noridian JE Part B — Southern CA Enrollment
PO Box 6775
Fargo ND 58108-6775

NOTE: Until requests to withdraw (opt-out) from the Medicare Provider has been approved, dentists are required by law to abide with all Medicare rule and regulations.

3. Enroll as a Medicare ordering and referring provider

Regardless of whether a dentist has opted in or out as a Medicare provider, the dentist may enroll as a Medicare ordering and referring provider. As an ordering and referring provider, dentists do not send claims to Medicare for payment. By registering as an ordering and referring provider, dentists will be placed on the Medicare Ordering and Referring Registry and will be able to order and refer patients to Medicare-enrolled providers and suppliers.

Dentists should take action regarding their Medicare provider enrollment by June 1, 2015, to minimize negative impact to their patients, local pharmacies and other dental providers. Pharmacies, specialists and pathologists may not be reimbursed for prescriptions, treatment and lab work when referred by a dentist who has failed to enroll as a Medicare provider, enroll as a Medicare ordering or referring provider or opt out of the program altogether.

CMS issued the final rule to comply with the Affordable Care Act and extended the Medicare enrollment requirements to physicians and eligible professionals who order or certify other categories of Medicare items or services, including covered Part D drugs. In the final provisions document, CMS estimates a cost savings of approximately $1.6 billion over the next 10 years (2015-2024) as the result of improved program efficiencies, clarified program requirements and improved payment accuracy. Additionally, the regulations expand CMS efforts to combat fraud and abuse in Part D.

More Medicare information can be found on cda.org and ada.org.

Updated: 11/17/16