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ADA applauds CMS decision to remove Part C, D requirements

November 17, 2017

By Jennifer Garvin

Baltimore — The Centers for Medicare and Medicaid on Nov. 16 announced proposed changes to Medicare drug plans, including rescinding the requirement that dentists enroll in or validly opt-out of Medicare in order for a Part D drug prescriptions to be covered.

In addition to removing the Part D mandate, CMS said the proposed rule would implement changes that are part of the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act. These include revisions to the Medicare Advantage and Prescription Drug Benefit regulations, improvements to the CMS customer experience and addressing program integrity policies.

Getting CMS to remove the Medicare Part D enrollment requirement for dentists has been a key priority of the Association’s advocacy efforts for more than three years, since CMS published a final rule in May 2014 stating that prescribers must be enrolled in or opted-out of Medicare Part B prior in order for their written prescriptions to be covered under Part D.

The proposed rule also contains changes to Medicare Part C, including rescinding the current provision requiring dentists be enrolled in Medicare in order to provide supplemental services to patients enrolled in Part C, also known as Medicare Advantage plans. The new rule proposes that Medicare Advantage organizations not pay for these services if the provider is on CMS' “preclusion” list, which would “consist of certain certain individuals and entities that are currently revoked from the Medicare program.”
The ADA believes this is good for patients because more dentists will likely enroll in these insurance programs without the duplicate paperwork requirements.

“This is great news for dental patients,” ADA President Joseph P. Crowley said. “The ADA has fought to have these unnecessary and duplicative paperwork requirements reformed and we are glad to see CMS recognizes the need to minimize interruptions to patients’ access to needed care and medications.”

As a replacement to the Part D enrollment requirement, CMS is proposing that Part D plan sponsors reject, or require their pharmacy benefit managers to reject, pharmacy claims for Part D drugs “if the individual who prescribed the drug is included on the ‘preclusion list,’ ” which would include certain prescribers who are currently revoked from the Medicare program or have engaged in behavior for which CMS could have revoked the prescriber.

“We recognize, however, the need to minimize interruptions to Part D beneficiaries’ access to needed medications,” said CMS in communications. “Therefore, we also propose to prohibit plan sponsors from rejecting claims or denying beneficiary requests for reimbursement for a drug on the basis of the prescriber’s inclusion on the preclusion list, unless the sponsor has first covered a 90-day provisional supply of the drug and provide individualized written notice to the beneficiary that the drug is being covered on a provisional basis.”

The proposed rule is expected to be published Nov. 28 and would likely be finalized in 2018.

In a Nov. 1 letter from ADA President Joseph P. Crowley and Executive Director Kathleen T. O’Loughlin to the House Ways and Means Committee, the Association noted that if the mandate is not removed, “many seniors will not have access to the dental care they pay for in their Medicare Advantage plan from the dentists of their choice or the prescription coverage they are promised when they enroll in Part D.”

Also on Nov. 1, the Association announced its support for the Protecting Seniors Access to Proper Care Act of 2017, proposed legislation from Rep. Kenny Marchant, R-Texas, that supports removing the mandate for dentists — and other providers who are low prescribers and do not participate in Medicare.

For information on all of the ADA’s advocacy efforts, visit