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Update: CMS delays Medicare enforcement until Feb. 1, 2017

March 07, 2016

By Kelly Soderlund

Editor's note: A story appeared in the March 7 print ADA News stating dentists had less than 90 days to enroll in Medicare or opt out if they wanted to prescribe Part D covered drugs to Medicare beneficiaries. The Centers for Medicare & Medicaid Services announced March 4 — after the March 7 issue had gone to press — a change in the deadline. This story reflects that change.

Washington — The federal government once again delayed the deadline for dentists who prescribe Part D covered drugs to Medicare beneficiaries to enroll in the program or opt out.

Dentists now have until Feb. 1, 2017, to take action, otherwise Part D prescription drug claims for Medicare eligible patients will not be covered. If dentists want Part D plans to continue covering drugs prescribed for their Medicare patients, they must either enroll as an ordering/referring provider by filling out form 855O or enroll as a Medicare provider through form 855I. Otherwise, they must opt out of the program.

CMS encourages health care providers to submit their Medicare enrollment applications or opt-out affidavits to their Medicare administrative contractors before Aug. 1 to allow time for processing. It's the fourth time CMS has delayed the deadline.

"Any way you slice it, dentists have to take action or their patients may suffer the consequences," said Dr. Ronald Riggins, chair of the ADA Council on Dental Benefit Programs.

Photo of Dr. Riggins
Dr. Riggins
If dentists do not take any action, the first time they 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 stating that because of the dentist's Medicare enrollment status, the drug will not be covered after the first three months. Part D plans are also required to attempt to notify the prescribing dentist. After three months, if the dentist still has not taken action to enroll or opt out, the Part D plan will deny coverage for that patient's prescription.

Dentists who choose to opt out cannot receive payment from a Medicare Advantage plan. Their patients also cannot receive payment. Dental practices may not be aware that a patient's dental plan is a Medicare Advantage plan.

Currently, as mandated by a similar federal regulation in 2012, if a dentist sends a biopsy to an oral pathology laboratory for a Medicare patient, the oral pathologist will not be paid unless the dentist either enrolled in Medicare to provide covered services; enrolled in Medicare to order and refer; or formally opted-out. The same is true of orders for other clinical laboratory services, as well as imaging services and Durable Medical Equipment, Prosthetics, Orthotics and Supplies.

A dentist who elects to opt out of Medicare must file an affidavit with the appropriate Medicare contractor and meet other compliance obligations.

"Remember, opting out is not the same as doing nothing," Dr. Riggins said.

Congressmen Kenny Marchant, R-Texas, and Earl Blumenauer, D-Ore., introduced legislation, with collaboration from the American Dental Association, in November that removes the mandate that certain health care providers be enrolled in Medicare in order for Part D plans to cover prescriptions. H.R. 4062 is currently awaiting committee action.

Visit CMS.gov for more information and to access forms 855O and 855I. The ADA Center for Professional Success also has links to the forms and a video tutorial on the process at Success.ADA.org/practice/Medicare/Medicare.