Medicare is the federal health insurance program for:
- Individuals 65 or older;
- Younger individuals with disabilities; and
- Individuals with End-Stage Renal Disease.
The Centers for Medicare and Medicaid Services (CMS) published a final rule in May that requires all eligible professionals - including dentists - to be enrolled in Medicare or opt-out in order for Medicare beneficiaries to receive pharmaceutical benefits.
Dentists, who write prescriptions for Part D drugs are to be enrolled in an approved status or validly opted out with Medicare, in order for their patients’ prescriptions to be covered under Medicare Part D.
Full enforcement of Part D prescriber enrollment requirement will begin on January 1, 2019. In the lead up to the January 1, 2019 full enforcement date, CMS will begin targeted enforcement and through additional safeguards to increase prescriber enrollment, identify and eliminate vulnerabilities, and strengthen the Medicare Part D program. To learn more about these additional safeguards, click here.
In order to opt-out, the affidavit must be mailed to the Medicare Contractor for your state. Illinois dental practices should mail their opt-in or opt-out forms to:
Medicare Part B Contractor
National Government Services, Inc.
PO Box 6475
Indianapolis, IN 46206-6475
Sample private contract for dentist and patient
How can I enroll in Medicare?
- Providers can enroll in Medicare by using either PECOS: go.cms.gov/pecos or by completing the paper 855I or 855O paper application.
- By using internet-based PECOS to submit your enrollment application, Dentist can easily enroll in Medicare without paying expensive consulting firms. Please visit the tutorial video on how to use internet-based PECOS at: Go.cms.gov/PECOSVideo. This video is specific to dentists.
- When submitting paper applications, the information should be submitted through their respective Medicare administrative contractors (MACs). Contact information for MACs can be found here: go.cms.gov/partdmaclist
- CMS 855I – allows you to enroll to be reimbursed for the covered services furnished to Medicare beneficiaries, order and certify certain items or services, and prescribe Part D drugs. Please note: CMS is updating the CMS-855O to include the General Dentist option. Until that form is updated, dentists should select from either the Maxillofacial Surgery, Oral Surgery (dentist only), if applicable, or select Undefined Physician type and write in ‘General Dentist’ on the CMS-855O.
- CMS-855O – a shorter, abbreviated form, which allows you to enroll solely to order and/certify and/or prescribe Part D drugs. (While the CMS-855O form states it is for physicians and non-physician practitioners who want to order and refer, it is appropriate for use by prescribers who also want to enroll to prescribe Part D drugs.) Please note: CMS is updating the CMS-855O to include the General Dentist option. Until that form is updated, dentists should select from either the Maxillofacial Surgery, Oral Surgery (dentist only), if applicable, or select Undefined Physician type and write in ‘General Dentist’ on the CMS-855O.
If you choose not to enroll or opt out of Medicare, please be aware:
- Unenrolled dentists’ Medicare patients will receive written notifications in the mail that their dentist is not qualified to write Part D prescriptions when the patients fill a prescription (which will only be covered on a provisional basis).
- After a provisional supply of a drug has been covered, a Part D drug benefit plan will no longer cover a prescription written by an unenrolled dentist.
- Unenrolled dentists who contract with managed care plans to provide dental services to Medicare beneficiaries cannot opt-out.
Opt Out Affidavits
Opt Out of Medicare Enrollment
Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare. This means that neither the physician/practitioner, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician/practitioner out-of-pocket and neither party is reimbursed by Medicare. A private contract is signed between the physician/practitioner and the beneficiary that states, that neither one can receive payment from Medicare for the services that were performed. The physician or practitioner must submit an affidavit to Medicare expressing his/her decision to opt-out of the program. For more information please review MLN Matters Number: SE1311 at go.cms.gov/optoutinfo.
Opt out periods last for two years and cannot be terminated early unless the physician or practitioner is opting out for the very first time and the affidavit is terminated no later than 90 days after the effective date of the physician or practitioner’s first opt out period.
Opt-out affidavits signed on or after June 16, 2015 will automatically renew every two years. Therefore, physicians and practitioners that sign valid opt-out affidavits on or after June 16, 2015 will no longer be required to file renewal affidavits. Physicians and practitioners that file valid opt-out affidavits effective on or after June 16, 2015 and do not want to extend their opt-out status at the end of a two year opt-out period may cancel by notifying all Medicare contractors with which they filed an affidavit in writing at least 30 days prior to the start of the next two year opt-out period.
Section 106(a)(2) of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 requires that a list of all physicians and practitioners that have chosen to opt-out of Medicare be made available to the public.
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services (CMS) has published a Med Learn Matters article titled: Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs which can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1434.pdf.
How can I check my enrollment status? You may check your enrollment status (Opt In) here or (Opt Out) here.
FREQUENTLY ASKED QUESTIONS:
As a dentist, what choices do I have?
A dentist may:
- opt-in to Medicare for billable procedures using CMS Form 855i;
- opt-in to Medicare to prescribe and refer using CMS Form 855o; or
- opt-out of Medicare by completing an affidavit and entering private contracts with each Medicare eligible patient.
Isn’t Medicare pretty much the same as Medicaid?
No. Medicare is the federal health insurance program for individuals 65 or older, younger individuals with disabilities, and individuals with end-stage renal disease. Medicaid is a joint federal and state program for individuals and families with limited income and resources.
What dental services will Medicare cover?
Medicare does not cover routine dental care; however, Medicare will cover some dental services required to protect a patient’s general health, such as:
- an oral exam prior to a kidney transplant or heart valve replacement;
- dental services necessary for radiation treatment that involve the jaw (oral cancer);
- dental services following removal of a facial tumor; and
- surgery to treat fractures of the jaw or face.
Where do I find the fee schedule for Medicare covered services?
Reimbursement fees can be found at the National Government Services website at www.ngsmedicare.com. National Government Services is a Medicare contractor headquartered in Indianapolis, Indiana.
If I opt-out of Medicare, can I still submit claims to a Medicare Advantage plan?
If I opt-out of Medicare, how long does that last?
Once you file an affidavit to opt-out of Medicare, you are out of Medicare for two years from the date the affidavit is signed. If you opted-out on or after June 16, 2015 your status will be auto renewed. If you opted out prior to June 16, 2015, you will need to manually renew your opt-out status. If you intend to change your opt-out status to opt-in, you will need to notify the Medicare contractor 30 days prior to your renewal date.
When does a private contract need to be signed?
You may see Medicare patients in the office after opting out, but only if they sign a private contract acknowledging that you have opted out, Medicare will not pay for services and the patient is responsible for the bill.
I practice with two other dentists, can we just complete one form?
No. Each dental provider will need to enroll or opt-out.
I have decided to enroll and plan to offer sleep apnea appliances to Medicare beneficiaries. Do I need to do anything else?
You would be categorized as a supplier of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS); therefore, you would need to submit a CMS Form 855s along with a fee of $553.
Which option are most dentists choosing to do?
Each dentist should choose the option that best reflects his or her own patient population and dental services provided in the practice.
Since Illinois allows dentists to provide flu vaccinations, I may consider offering it to my patients. Can I opt-out and still submit claims to Medicare?
No. If you plan to give flu vaccinations to Medicare beneficiaries, you should consider opting in.
When attempting to complete an enrollment form, I could not identify myself as a dentist. What box do I check?
The enrollment form lists two options appropriate for dentists: maxillofacial surgery and oral surgery (dentist only). Oral and maxillofacial surgeons may use the maxillofacial surgery category while all other dentists should use the oral surgery (dentist only) category.
What will happen if I choose to not enroll or opt-out of Medicare?
If you do nothing, your Medicare eligible patients will not receive their pharmaceutical benefits.