Dentists should choose their Medicare status now

By Greg Alterton, CDA Dental Benefit Plan Specialist

Now is the time for dentists to file their intentions with Medicare.

Medicare has given dentists and other health care providers until June 1, 2016, to declare whether they will opt in or opt out of the program. However, the Centers for Medicare and Medicaid Services (CMS) is encouraging providers to get their forms into the state Medicare administrator by the first of the year to assure that a provider's status is recorded by the June 1 date, as it will take the administrators four to six months to process forms. 

Medicare does not cover routine dental procedures. It does cover certain dental procedures that have corresponding medical codes — mainly oral surgery, periodontal surgery and lab work, for example. For specialists or general dentists who perform procedures for which there are medical cross-codes, CMS is allowing an opt-in to Medicare as a provider, which will allow dentists to be reimbursed for those procedures. But again, for basic oral health care — preventive, diagnostic, basic restorative — Medicare does not provide coverage, and for dental care provided to patients who are Medicare beneficiaries, that care will have to be paid on a cash basis.   

Aside from enrollment, Medicare allows dentists to opt out. The opt-out lets CMS know that a provider chooses not to participate in Medicare, and that any services provided to a senior who is in the Medicare program will be provided through a private arrangement between the practice and the patient. The importance of formally opting out is that if a dentist who has opted out writes a prescription for a Medicare-covered patient, Medicare will pay for the medication. If a dentist does not at least opt out of Medicare, the patient will be paying for his or her prescriptions out of pocket.

A third option is to enroll with Medicare as an ordering and referring provider. This status does not allow the provider to bill Medicare for services, but does allow the provider to bill Medicare Advantage plans (privately administered Medicare coverage that often includes dental coverage provided by the plan administrators). 

A fourth option is to do nothing – to not file anything with Medicare. There is no penalty to the dentist who chooses to do nothing by the June 1 deadline, but after June 1, Medicare-covered patients will be paying for their medications out of pocket, unless the dentist formally opts out of Medicare.

To opt in to Medicare, a provider must submit a CMS Form 855i to the state's Medicare administrator. To register as an ordering and referring provider, CMS Form 855o must be submitted. Both of these forms are available on the CMS Medicare website and can be found easily with an Internet search of "CMS Form 855i" or "CMS Form 855o."

A sample of the opt-out form, and the private contract that must be entered into with cash-pay Medicare patients, are both available at ada.org.

All forms must be submitted to Noridian Healthcare Solutions, Provider Enrollment, P.O. Box 6770, Fargo, ND 58108-6774 (for Northern California, or ZIP code 58108-6775 for Southern California). 

Detailed questions can be brought to Provider Enrollment at Noridian, which can be reached at 855.609.9960.

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