Take action to enroll or opt out of Medicare

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

CDA Practice Support continues to receive many questions about the approaching deadline for  providers to opt in or out of the Medicare system. The Q-and-A below provides some basic facts about Medicare, dentistry and participating as a Medicare provider.

Q:  Does Medicare cover dental procedures?
A: No … and yes. Medicare does not cover dental procedures (anything designated with a CDT code), but Medicare will pay for procedures performed by a dentist that have a medical code assigned to it, but is a very limited scope. 

Q:  Who should consider enrolling as a provider in Medicare?
A:  As follow-up to the answer above, those dentists who provide services on a regular basis that can be claimed to medical plans might consider enrolling as a Medicare provider. This would likely be oral surgeons, dentists who perform a significant number of periodontal surgery procedures, such as bone and tissue grafts, or dental pathologists who perform analyses of biopsies. In short, specialists who perform procedures for which there are medical codes should consider enrolling as Medicare providers. Those wishing to enroll must submit a completed CMS Form 855i to the state's Medicare administrator.

Q:  What is the "ordering/referring" provider status?
A:  An ordering/referring provider is another provider category of Medicare, but such providers are not able to submit claims to Medicare for reimbursement because they are technically not "participating" providers in Medicare. The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare, wrote a regulation that defines this category to be:
(1) a provider who "orders" non-physician items or services for the beneficiary, such as Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), clinical laboratory services, or imaging services; and (2) a provider who "certifies" home health services for a beneficiary. 

In terms of functionality, most dentists don't function in capacities that might be covered by Medicare. 

How the ordering/referring category would apply to dentists should be thought of this way:  Functionally, it is not different from the opt-out category (see below for discussion of opt-out category) in that an ordering/referring provider cannot send claims to Medicare. However, it is different in that CMS made a decision a year ago that providers who opted out cannot submit claims to Medicare Advantage plans administered by third party payers. Medicare Advantage plans are privately administered Medicare plans offered primarily by commercial medical plans such as Anthem, Aetna and Humana, through which these administrators add on dental coverage. The dental coverage portion of a Medicare Advantage plan is not paid by Medicare, but is identical to dental coverage offered by a commercial insurer. However, CMS's decision that an opted-out dentist cannot submit claims for dental care to a Medicare Advantage plan creates a prohibition for the dentist who has opted out. An ordering/referring provider may submit claims to Medicare Advantage plans, so the dentist who sees a significant number of senior patients covered by Medicare Advantage should consider the ordering/referring provider category. That is the only real advantage to a dentist in enrolling as an ordering/referring provider, which can be done by submitting the CMS Form 855o to the state's Medicare administrator.

Q:  I fabricate sleep apnea devices.  How should I enroll with Medicare if I want to submit claims for these devices?
A: This is an entirely different provider category:  Medicare Enrollment Application — Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Suppliers. That would require submission of CMS Form 855s. Be aware that Medicare will only pay for a specific type of sleep apnea device based on CPAP technology.

Q:  What is the participation in Medicare Part D that I am hearing about?
A:  Medicare Part D is the medication/prescription benefit within Medicare. Commercial pharmacies and pharmacy chains are sending out notices to dentists urging them to enroll in an appropriate provider category to enable their patients to take advantage of their Part D medication coverage. What the pharmacies are really saying is that if a dentist enrolls in one of the Medicare categories, they, the pharmacies, will be able to be reimbursed for filling prescriptions for Medicare patients so the Medicare recipient will not have to pay out of pocket. CMS rules allow prescriptions to be paid for only if either an enrolled Medicare provider, an ordering/referring provider or an opted-out provider orders them.

The Medicare opt-out category tells Medicare that a provider intends not to participate in Medicare, meaning claims will not be submitted to Medicare for reimbursement. By act of Congress, a provider, such as a dentist who specifically opts out of Medicare, may order a prescription for a Medicare-covered patient and Medicare will pay for that prescription. Therefore, the advantage of formally opting out of Medicare is that it extends the drug benefit of Medicare to senior patients. A dentist can opt out of Medicare by submitting to the state Medicare administrator the opt-out affidavit and a sample private contract for use with Medicare patients. Both the affidavit and the sample contract can be found on the website for California's Medicare administrator, Noridian Healthcare Solutions: med.noridianmedicare.com/web/jeb/enrollment/opt-out.

Q:  If I opt out of Medicare, may I still refer Medicare beneficiaries to specialists, whether physicians or oral surgeons, and have those services paid by Medicare?
A:  Yes. Medicare will pay for medical procedures performed by providers enrolled in Medicare, whether physicians, oral surgeons, labs or radiological services.

Q:  Where can I obtain the enrollment forms for Medicare?
A: The forms are readily available online by simply searching "CMS Form 855i," "CMS Form 855o" or "CMS Form 855s."

Q:  What if I choose to do nothing –  neither enroll in Medicare nor opt out?
A: As a provider, there is no penalty against you if you choose to do nothing in regard to Medicare enrollment options. However, there will be consequences for your senior patients who utilize Medicare Part D to cover prescription drugs. Failure to opt out will mean that any prescriptions ordered by you for the patient will have to be paid directly by the patient, out of pocket. This is why the vast majority of dentists are deciding to at least formally opt out – as a benefit to their senior patients.

Q:  When is the deadline to submit enrollment or opt-out forms to Medicare?
A: This has been an area of confusion because CMS has changed the deadline date numerous times. Recently, CMS changed the deadline again to Feb. 1, 2017. CMS has urged providers to submit one of the enrollment or the opt-out forms four or five months in advance of the compliance deadline, because it is taking CMS that long to process the forms.

Q:  Where should enrollment or opt-out forms be sent?
A: Medicare enrollment forms, as well as the opt-out forms, are being processed by Noridian Healthcare Solutions, the Medicare administrator for California. Send completed forms 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). For additional information, Provider Enrollment at Noridian can be reached at 855.609.9960.

For additional CDA Practice Support resources, visit cda.org/practicesupport.

Updated: 11/17/16

Related Items

The Centers for Medicare and Medicaid Services has extended the deadline for dentists to either enroll as a Medicare Part D "ordering/referring provider" or opt out of the Medicare program entirely. The previous deadline was June 1, but it has now been extended to Feb. 1, 2017.