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ADA offers Q&A primer on opting in or out of Medicare

August 18, 2014 In response to member questions, the ADA Practice Institute has put together the following Q&A to help clarify which practitioners should opt in or out of Medicare.

Dentists who treat Medicare patients must either enroll in the program or opt out in order to prescribe medication to their qualifying patients with Part D drug plans.

The requests to the ADA for more information came in response to a June 16 ADA News article alerting dentists to the program requirements.

Q: I read the June 16 article in the ADA News that I have to opt in or out of Medicare or else Medicare won't pay for the prescriptions I write for my patients who have Medicare Part D prescription drug coverage. How do I go about this?

A: In order for Medicare to pay for prescriptions under Medicare Part D, a dentist must do one of the following:

  • Enroll as a Medicare provider
  • Opt-out of the Medicare program.
  • Enroll as an ordering/referring provider.

Q: If I opt out of Medicare, will my Medicare eligible patients still receive their Part D prescription drug coverage?

A: Yes, as confusing as this may be, once a dentist is in the Medicare system either by enrolling in or opting out, patients are eligible to receive their Part D prescription drug coverage.

Q: If I already enrolled as a Medicare ordering/referring provider do I need to take more action?

A: No. Since you are now in the system, your Medicare patients will be eligible for Part D prescription drug coverage.

Q: What happens if I choose not to do any of the above?

A: If you choose to do none of the above, your Medicare eligible patients will have their prescription drug coverage denied for the prescriptions you write.

Q: What if I do not see any Medicare patients or do not prescribe drugs for Medicare patients?

A: If you do not see any Medicare patients or do not prescribe drugs for Medicare patients, then you do not need to do anything.

Q: When does this new regulation take effect?

A: This new regulation takes effect June 1, 2015.

Q: This seems like it will create an unnecessary burden on dentists. What has the ADA done to help its members?

A: The ADA has voiced its opposition to this requirement twice in letters to the Centers for Medicare & Medicaid Services and will continue to advocate on behalf of our member dentists.  

Q: When does a private contract need to be signed?

A: When a patient wants to receive a Medicare-covered service and understands that the dentist has opted out of the program and is willing to pay out of pocket, a private contract should be signed. A private contract is not necessary for the patient to be eligible to receive Part D prescription drug reimbursement prescribed by a dentist who has opted out of the program.

Q: My Medicare patient has a private dental benefit plan and it is not a Medicare Advantage plan. Must I enroll in Medicare to treat this patient?

A: No. You only need to enroll in Medicare if you are going to provide Medicare-covered dental services to patients on Medicare. If this patient has a prescription drug plan under Part D of Medicare, you would need to take some action (one of three identified in question one) to allow the patient to benefit from the Part D coverage when you prescribe covered medicine for the patient.

Q: Where can I find additional information on the Medicare program, both enrollment and opting out?

A: For information on how to enroll in or opt-out of Medicare, please visit Success.ADA.org/medicare.

Q: I tried completing the enrollment form but could not identify myself as a dentist. My local Medicare contractor informed me that dentists cannot enroll in Medicare. Is that true?

A: It is not true. Dentists are specifically included in the Medicare definition of a physician. The Medicare enrollment form for a Medicare provider (CMS form 8551) lists two options appropriate for dentistry under Physician Specialty in Section 2: Maxillofacial surgery and oral surgery (dentist only). The specialty of oral and maxillofacial surgery may use the maxillofacial surgery category; all other dentists should use the oral surgery (dentist only) category. However, it is true that some Medicare contractors are erroneously stating that dentists cannot enroll. The ADA is working with CMS to help get this issue resolved. If enrolling as an ordering and referring provider using the CMS form 8550, the section on identifying information includes a number of organizations such as the Department of Veterans Affairs or the Public Health Service. Assuming the dentist is not employed by one of the organizations listed, the dentist should enroll by checking the box for "Dentist not employed by any of the above."

The ADA is also awaiting guidance from CMS on the impact of opting out of the Medicare program on Medicare Advantage plans. The ADA Center for Professional Success will post updates on this issue at Success.ADA.org/medicare

Read the original June 16 ADA News article here.