Medicare opt-out excludes Medicare Advantage

As most know, the Affordable Care Act of 2010 allows nonphysician health care providers to enroll as providers in the Medicare program or, alternatively, to formally opt out of Medicare. An amendment to the ACA allows providers who formally opt out of Medicare to write drug prescriptions for their patients, and Medicare will pay for those medications even though Medicare does not reimburse providers who opted out for basic care they rendered.

Most dentists have chosen to opt out of Medicare, but there’s another Medicare category that dentists should consider: Registering with Medicare as an Ordering and Referring provider.

What category, if any, a dentist should choose with Medicare is complicated by the fact that Medicare does not cover routine dental procedures. It will cover certain dental procedures that have a corresponding medical code — mainly oral surgery, periodontal surgery and lab work, for example. The federal Centers for Medicare and Medicaid Services allows specialists or generalists who perform procedures for which there are medical cross-codes to opt in to Medicare as a provider. This lets them be reimbursed for those procedures. But, again, for basic oral health care such as preventive, diagnostic and basic restorative, Medicare does not provide coverage. Most dental care provided to patients who are beneficiaries within Medicare is paid on a cash basis.  

In what has become a series of delays in the compliance date, CMS is now giving dentists until Jan. 1, 2019, to decide if they want to opt in or out of Medicare. Dentists who choose the opt-out are letting CMS know they are choosing not to participate in Medicare and that any services provided to a patient covered by Medicare will be provided through private arrangement between the practice and the patient. The provider who opts out will not be able to submit a claim to Medicare, even if a procedure is a covered benefit in Medicare. However, Medicare will pay for the prescription for any dentist who has opted out of Medicare and who writes a prescription for a Medicare beneficiary.

While there is no penalty to the dentist who chooses not to opt out and who essentially doesn’t register as any other provider status, the dentist’s patients will need to pay out-of-pocket for their own medications. Therefore, most dentists are choosing to opt out to benefit the patients who are obtaining prescriptions.

However, another decision by CMS has caused problems for dentists who opt out. Medicare Advantage plans provide an option for seniors to enroll with a commercial administrator for Medicare benefits that let the beneficiary’s Medicare benefits be administered in a similar way to private insurance. Most of these Medicare Advantage plans have additional riders attached to the medical benefits. One typical rider is dental coverage that enrollees may obtain through payment of an additional premium. This makes it possible for a dentist to treat a patient who has Medicare Advantage and to submit a claim to the Medicare Advantage administrator as they would to any other dental insurer.

CMS made the decision that any provider (including a dentist) who sees a Medicare Advantage enrollee must at minimum be registered as an Order/Referring provider with Medicare. Being “opted out” will not permit a provider to submit claims to a Medicare Advantage plan. Most Medicare Advantage medical plans contract with dental plans to provide the networks for the dental coverage being offered to Medicare enrollees. A dentist in the network of one of these dental plans utilized for Medicare Advantage who has formally taken the opt-out route for Medicare will not be able to remain in the dental plan contract and will have their contract terminated because of CMS’s rule that opted-out providers cannot participate in Medicare Advantage plans.

So, a dentist would need to register with Medicare as an Ordering and Referring provider if the dentist sees patients covered by a Medicare Advantage plan and submits dental claims to the patient’s plan for the dental care the practice provides. The Ordering/Referring provider form is the CMS 855o (the letter “o”). The 855o form can be readily found on the CMS site or simply through an internet search for “CMS form 855o.”

In summary:

  • You may submit an opt-out affidavit along with a sample private contract you will be using when providing care to Medicare beneficiaries, and Medicare will pay for those patients’ medications.
  • If you are in a dental plan network used by a Medicare Advantage plan and have opted out of Medicare, the dental plan will likely terminate you from its network. (This is the case even though the compliance deadline for Medicare enrollment is Jan. 1, 2019. Dental plans are already removing opted-out dentists from their networks.)
  • To remain in dental networks used by Medicare Advantage plans and to be able to submit dental claims to Medicare Advantage plans, the preferred enrollment alternative is Ordering/Referring provider using the CMS Form 855o.
  • Registering with Medicare in the Ordering/Referring category does not enroll a dentist as a Medicare provider. That category will allow a dentist to participate within networks used by Medicare Advantage plans and will allow the dentist to submit claims to those plans. Registering as an Ordering/Referring provider will allow Medicare to pay for patient’s medications prescribed by a dentist.

As with the opt-out affidavit, the 855o form must be submitted to the Medicare administrator for the state. For California, the administrator is Noridian Healthcare Solutions.

For dentists with an address in Northern California, forms must be submitted to:

Noridian JE Part B - Northern CA Enrollment
P.O. Box 6774
Fargo, ND 58108-6774

If in Southern California, the address is:

Noridian JE Part B - Southern CA Enrollment
P.O. Box 6775
Fargo, ND 58108-6775

For additional information on submission of Medicare enrollment forms, call Noridian Provider Enrollment at 855.609.9960 between 6 a.m. and 5 p.m., PST.

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