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ADA formally comments on proposed changes to Medicare Parts C, D

January 16, 2018

By Jennifer Garvin

Baltimore — The ADA filed comments Jan. 12 on the proposed changes to the enrollment requirements for Medicare Part C and Part D.

Thanks in part to significant advocacy efforts from the ADA, the Centers for Medicare and Medicaid Services announced Nov. 16 plans to rescind certain Medicare Part D and C requirements for providers that would mean dentists no longer need to enroll in or opt out of Medicare to continue to provide dental care and prescriptions for Medicare Advantage and Part D drug plan beneficiaries. Now the agency is asking for input to implement these changes.

In a letter to CMS, ADA President Joseph P. Crowley and Executive Director Kathleen T. O'Loughlin said the ADA supports creating a preclusion list as a substitute for the enrollment or opt-out requirement under Medicare Part D and asked CMS to "streamline the existing regulations because, given that we would no longer be requiring certain prescribers to enroll or opt out, we would no longer need an exception for 'other authorized providers,' as defined in [the rule] for there would be no enrollment requirement from which to exempt them. Instead, we would require plan sponsors to reject claims for Part D drugs prescribed by prescribers on the preclusion list.

"We believe this latter approach would better facilitate our dual goals of reducing prescriber burden and protecting the Medicare program and its beneficiaries from prescribers who could present risks," Drs. Crowley and O'Loughlin wrote.

The ADA also supports requiring Medicare Advantage organizations (Part C) to follow a documented process that ensures compliance with the preclusion list provisions to avoid confusion for providers and suppliers.

The ADA also offered additional comments on the proposed CMS rules implementing the Comprehensive Addiction and Recovery Act of 2016, including supporting CMS's goal of helping to address the opioid epidemic by providing a framework for Medicare Part D drug plan sponsors to establish drug management programs for beneficiaries at risk for prescription drug abuse or misuse.

In implementing the Comprehensive Addiction and Recovery Act, the ADA urged CMS to:

  • Require plan sponsors to include a dentist in case management teams.
  • Permit prescribers to "agree, disagree, or neither agree nor disagree during clinical contact" when a plan sponsor makes clinical contact to determine whether a beneficiary is at risk or whether to implement a claim edit or lock-in.
  • Prohibit plan sponsors from making contact via the telephone with prescribers in order to avoid disrupting their practices and to reduce the risk of phishing and other attempts to trick prescribers into disclosing patient information.
  • Prevent phishing by requiring plan sponsors' policies and procedures for clinical contact to include secure identity verification safeguards.
  • Eliminate the requirement that a prescriber must be in-network if the plan sponsor imposes a limit on a beneficiary's access to coverage to a selected prescriber or prescribers.
  • Prohibit provider agreements from requiring prescribers to agree in advance to serve if selected when the plan sponsor limits an at-risk beneficiary's access to frequently abused drugs.
  • Require plan sponsors to notify prescriber and obtain prescriber's prior written confirmation before informing a beneficiary of the selection of the provider in connection with a limitation on the beneficiary's access to coverage of frequently abused drugs.
  • Prohibit plan sponsors from selecting a prescriber in connection with a limitation on a beneficiary's access to coverage of frequently abused drugs, if the selection might involve a violation of applicable scope of practice limitations.
  • Permit group practices to designate one or more prescribers when a plan sponsor intends to limit a beneficiary's access to coverage of frequently abused drugs to a selected prescriber or prescribers at a group practice and permit the group practice to modify such designation from time to time. Also: Require the plan sponsor to honor any such designation or modification. This should apply whether or not the prescribers at the group practice are all associated with the same single Tax Identification Number.
  • Require that the second beneficiary notice, as well as the first beneficiary notice, include a description of all state and federal public health prescription drug abuse resources to which the beneficiary has access.

The ADA also asked CMS to rewrite section 6405 of the Patient Protection and Affordable Care Act, which requires physicians who order items or services under Medicare to enroll in Medicare or opt-out, noting that "in spite of the efforts of CMS and the ADA, many dentists have chosen not to enroll in or opt-out.  

"We believe some of the same reasons that caused dentists to fail to comply with the Part D rule apply to the ordering and referring rule," Drs. Crowley and O'Loughlin wrote, adding that "applying the same preclusion list rules to items such as ordering laboratory tests or imaging services would prevent interruption in providing care to Medicare beneficiaries and will insure the integrity of CMS claims."

Drs. Crowley and O'Loughlin also pointed out that because of the confusion with the previous rule, some dentists chose to opt-out and now are no longer eligible to provide dental services for Medicare beneficiaries enrolled in Medicare Advantage and patients of those dentists are also precluded from filing claims. Currently, a dentist who opts out is allowed to withdraw the opt-out affidavit within the first 90 days; thereafter they are opted out for two years.  

"Many dentists did not learn of the impact on their participation in Medicare Part C plans until after the initial 90-day period had passed. Complicating the issue even more, CMS changed the rule so that effective June 16, 2015, unless the provider took affirmative action to withdraw the affidavit 30 days before the anniversary date, the enrollment automatically renewed for two more years."

Drs. Crowley and O'Loughlin noted that the ADA has received numerous calls from members who opted out in good faith trying to comply with the Medicare Part D rule only to learn later they were precluded from participating in Medicare Part C plans.  

"The ADA urges CMS to allow the Medicare Contractors to contact each dentist who has opted out giving them the opportunity to withdraw the affidavit. The ADA will work with CMS to publicize this effort to within the profession," they concluded.

Follow all of the ADA's advocacy efforts at ADA.org/advocacy.