Medicare Advantage might just give your practice an advantage

February 17, 2020

With baby boomers exiting the workforce and losing their employer-sponsored dental coverage, consumers are enrolling in Medicare, the federally administered health care program for all seniors age 65 and older. Practice Support has seen an uptick in member calls related to Medicare Advantage dental plans due, in part, to the aging patient population in their practices and increased Medicare enrollment.

Helpful Medicare facts for dentists to know:

  • Medicare varies greatly from Medicaid, commonly referred to as Medi-Cal or Denti-Cal in California. Medicare is a federally administered program, it reimburses providers differently and it does not typically cover dental care.
  • Medicare Advantage plans, known as Part C, include the benefits in Parts A (hospitalization) and B (outpatient, physician services) and, sometimes, Part D (prescription drugs).
  • Medicare Advantage plans frequently include additional coverage outside of the traditional Medicare coverage, many times including hearing, vision and dental benefits.
  • Medicare Advantage dental coverage may be sold as a separate policy and is frequently administered by well-known dental plans.

Since dental is not a required Medicare benefit, the Centers for Medicare & Medicaid Services gives dental plans some flexibility in terms of the benefit offered and payment policies. Some of the benefits and payment polices will replicate a commercial PPO and/or HMO product with similar plan design and compensation, while others will have varying benefits and limitations related to use of provider networks.

Some Medicare Advantage policies will not pay for services if the dentist is not contracted as a participating provider in the plan’s Medicare Advantage PPO network. This type of provider network is called an exclusive provider organization, commonly called an EPO in the dental industry.

Practice Support recently assisted a member dentist who received a claim denial stating no benefits could be paid as the dentist was outside of the network. The dentist was confused since he was a contracted provider in the well-known dental plan’s PPO network. Upon further analysis, Practice Support found that the patient was covered under one of the plan’s EPO Medicare Advantage policies. Since the dentist was not a contracted provider of the plan’s Medicare Advantage network, it was determined that no benefit was payable by the plan to the dentist for the services rendered.

As Medicare Advantage plan enrollment increases, the dentist and their staff should familiarize themselves with the Medicare Advantage products and coverage offered in their area. Practice Support recommends assigning a team member the task of verifying benefits for each and every Medicare Advantage patient to avoid claim denials and misinterpretations of the coverage.

Medicare opt-out has consequences
Practice Support has also received calls from members who’ve reported challenges with enrolling as a Medicare Advantage plan network provider because they previously opted out of Medicare. A CMS rule from June 2015 stated that dentists who provide dental care and prescriptions for Medicare Advantage patients and Part D beneficiaries would be required to be enrolled in Medicare or to opt out in order for their services to be covered. However, in April 2018, CMS published a final rule that rescinded dentists’ enrollment requirements for Parts C and D.

As of Jan. 1, 2019, CMS began utilizing a preclusion list in lieu of the enrollment/opt-out requirement. The list precludes those dentists who opted out of Medicare participation from receiving payment for Medicare Advantage services furnished to Medicare beneficiaries. Under the current rule, a dentist who opts out for the first time is allowed to withdraw the opt-out affidavit within the first 90 days; if they do not withdraw their affidavit, they are opted out for two years.

Additionally, the CMS 2015 rule noted that unless the provider took action to withdraw the opt-out affidavit 30 days before their opt-out anniversary date, the opt-out would automatically renew for another two years. For dentists who have opted out of Medicare and wish to have the flexibility to contract with Medicare Advantage plans in the future, Practice Support advises they take action 30 days prior to their opt-out anniversary date to rescind their opt-out affidavit. When the dentist receives confirmation that they are no longer opted out, they may reapply to the Medicare Advantage plan’s network.

CDA’s expert analysts are available to answer members’ questions about Medicare Advantage and other dental benefit issues. Members and their staff can use our Dental Benefits Issue Submission Form to submit a question online, and an analyst will evaluate it for possible resolution and communicate clear next steps.


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