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Medicare enrollment delayed

June 02, 2015

By Craig Palmer

Washington — The Centers for Medicare & Medicaid Services June 1 announced a delay in the enforcement of the Medicare Part D prescriber enrollment requirement to June 1, 2016.

The Association continues to seek a legislative repeal of the requirement that dentists who treat Medicare beneficiaries enroll in or opt out of Medicare to prescribe medication to their qualifying patients with Part D drug plans. Meanwhile, CMS once again delayed enforcement of the provision.

“This decision was based on CMS’ analysis of current Part D prescriber enrollment trends, and the strong concerns expressed recently by Part D sponsors and pharmacy benefit managers (PBMs) about their ability to make the complex system enhancements need to comply with the prescriber enrollment requirement due to the changes made by the IFC [interim final rule with comment],” the CMS Center for Program Integrity said in announcing the delay. The IFC comment period closes on July 6, 2015.

“However, we also have a responsibility to enforce this protection in a way that minimizes the potential for disrupting beneficiaries’ access to needed Part D medications and compromising continuity of care,” the CMS said in a PDF version of the announcement.

In response to member questions, the ADA Practice Institute offers a Q&A primer on opting in or out of Medicare.

Q. When does this new regulation take effect?

A. CMS has announced that it will delay enforcement of the new rule until June 1, 2016.

Q. When do I need to submit my enrollment application or opt-out affidavit?

A. CMS urges prescribers to submit their Medicare enrollment applications or opt out affidavits to their Medicare Administrative Contractors before Jan. 1, 2016.

Q. I have heard 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 by completing form 855I.
  • Enroll solely to prescribe drugs for patients on Medicare by completing form 855O.
  • Opt out of the Medicare program by completing the affidavit.
Q. What happens if I choose not to do any of the above?

A. As of June 1, 2016, this is what will happen if you choose not to do any of the above: The first time you write a prescription for a patient with a Medicare Part D drug plan, the plan will give the patient a provisional supply of the drug and a letter saying that because of your Medicare enrollment status the drug will not be covered after the first three months. The Part D plan must also make reasonable efforts to notify you. At the end of the three-month period, if you still have not done any of the above, the plan will deny coverage for any prescription that you give that patient for that drug.

Q. What is the difference between form 855I and form 855O?

A. Form 855I is used to enroll to provide Medicare covered services. Form 855O, which is significantly easier to complete, is used to register solely to prescribe drugs to Medicare beneficiaries and to order any of the following for Medicare beneficiaries: clinical lab services, imaging services, and durable medical equipment (such as an oral sleep apnea device). Sometimes such dentists are referred to as “ordering/referring” providers.

Q. When I tried to enroll using either form 855I or 855O, I did not see my specialty listed. What should I do?

A. Oral surgeons should use “maxillofacial surgery.” All other dentists should use “oral surgery (dentist only).”

Q. If I opt out of Medicare, will my patients who are on Medicare still receive their Part D prescription drug coverage for the prescriptions I write?

A. Yes. Once a dentist is in the Medicare system either by enrolling in or opting out, Part D plans will cover the prescriptions you write for your patients on Medicare.

Q. What is the impact of opting out if I participate with a Medicare Advantage plan?

A. Dentists who are considering opting out should understand that by opting out, dentists may be precluded from participating in and receiving payment from Medicare Advantage plans. Medicare Advantage is sometimes called “Medicare Part C.” Medicare Advantage plans, which offer Medicare benefits through private insurance, often offer dental and vision benefits not covered under original Medicare. Therefore, dentists may be treating patients enrolled in a Medicare Advantage plan through these enhanced benefits. If a dentist opts out of Medicare, he or she may not participate in a Medicare Advantage program.  A dentist who has enrolled using either the simplified 855O form or the full 855I form (see above) can receive reimbursement from a Medicare Advantage plan.

Q. What is the impact of opting out if I supply oral sleep apnea devices?

A. Oral sleep apnea devices may be covered by Medicare as durable medical equipment (DME). A dentist who wishes to receive reimbursement from Medicare for supplying oral sleep apnea devices must enroll as a DME supplier using the 855S form. By itself, enrolling as a DME supplier does not satisfy the requirement for Medicare coverage of Part D drugs. A dentist must also either enroll (using the 855I or the 855O form, as appropriate) or opt out. CMS has advised the ADA: “Dentists are permitted to opt out individually even though they are associated to an enrolled DME supplier.”

Q. How long does an opt-out last?

A. Once you file an affidavit notifying the Medicare carrier that you have opted out of Medicare, you are out of Medicare for two years from the date the affidavit is signed. If you change your mind after the carrier has approved your opt-out affidavit, the opt-out may be terminated within 90 days of the effective date of the affidavit.

After the two-year period, if you wish the opt-out to continue, you must file another affidavit.

Q. If I decide to opt out, where do I send my completed affidavit?

A. You must send the affidavit to each applicable Medicare contractor. You’ll need to send it to every Part B entity listed in the state(s) where you practice. Remember that you are looking for the Part B (physician and nonphysician provider) addresses, not Part A.

Q. If I decide to enroll, where do I send my form?

A. You can enroll online using the federal government’s Medicare Provider Enrollment, Chain, and Ownership System website. You can also enroll using a hard copy form. For more information and links to the forms, visit the CMS.

Q. How can I check my enrollment status?

A. Visit: Data.CMS.gov.

Q. Where do I find all the forms and more information?

A. Visit: Success.ADA.org.