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What is Medicare?

Medicare is a federal health insurance program that assists its enrollees in paying for many health care services. Medicare is available to Americans over 65 years of age, as well as some Americans under 65 with certain long-term disabilities.

Medicare is managed by the Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services. Traditional Medicare is administered locally by contractors known as Medicare Administrative Contractors (MACs).

Enrollees in Medicare still pay for a portion of their care through premiums, deductibles and copays, with Medicare typically covering 80% of costs. There are no annual or lifetime limits on the coverage Medicare provides. There are some services that are not covered by Medicare; among these are routine dental care (such as examinations, x-rays, and dentures) for healthy patients.

Medicare services are divided into four parts:

Part A covers inpatient services, such as hospital stays, hospices, and skilled nursing facilities.

Part B covers outpatient services, such as physician visits and preventive care.

Part C offers an alternative to traditional Medicare by allowing patients to opt for a Medicare Advantage health insurance plan. These plans are privately administered and offer Part A and B coverage, usually along with some supplemental coverage that is not offered through traditional Medicare (such as dental care).

Part D covers prescription drugs.

What is the difference between Medicare, Medicare Advantage and Medicaid?

While the goal of both Medicare and Medicaid is to help make medical care more accessible to vulnerable groups of people, they go about it in different ways and serve different groups of people. The biggest difference is the people they serve. While Medicare is available to anyone over age 65, and a limited number of people under age 65 with certain qualifying conditions, Medicaid serves people of any age with limited incomes.

Medicare Advantage is an option for individuals who qualify for Medicare. This is a plan chosen by the patient in which their Medicare benefits are administered by a private health insurer. These plans function like an HMO, POS, or PPO, and providers have to be enrolled within the private health insurer’s network to be utilized.

Medicare is managed by CMS entirely at the federal level, which sets cost and coverage standards that are uniform for all Medicare enrollees. In contrast, Medicaid is a joint program between federal and state governments, in which the federal government provides general regulations and funding, but each state manages its own program and provides matching funding. As such, eligibility and coverage vary from state to state.

Unlike Medicare, Medicaid enrollees generally aren’t responsible for any portion of the expenses from their covered services, beyond a small copay. Medicaid covers some services that Medicare does not; most notably, states are federally mandated to offer Medicaid coverage for dental services for Medicaid enrollees under age 21.



Medicare

Medicare Advantage

Medicaid

Serves

Age 65+ or those with certain disabilities

Age 65+ or those with certain disabilities

Low-income individuals

Managed by

Federal Government (CMS)

Private Insurers

Individual states (within federal guidelines)

Cost to enrollee

Premiums, deductibles, and copays (the same for all enrollees)

Premiums, deductibles, and copays (vary by insurer)

Copay, with some states requiring a small premium

Covers dental care?

Only medically necessary dental care connected with certain diagnoses

Varies by insurer

Yes, for enrollees under 21; coverage for enrollees over 21 varies by state


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How do I become a Medicare participating provider?

How do I enroll?

  • Document: Step-by-Step Guide – Provider – note there is no section for dentistry

What is covered?

In 2023, CMS began reimbursement for dental procedures that are inextricably linked to, and substantially related and integral to, the clinical success of otherwise covered medical procedures. Below is a list of procedures Medicare may cover:

  • Dental or oral exams as part of a comprehensive workup prior to the Medicare-covered services listed below, and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with these Medicare-covered services:
    o Organ transplant, including hematopoietic stem cell and bone marrow transplant
    o Cardiac valve replacement
    o Valvuloplasty procedures
    o Chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, and the administration of high-dose bone-modifying agents (antiresorptive therapy) when used in the treatment of cancer
  • Dental or oral exams as part of a comprehensive workup prior to medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, and medically necessary diagnostic and treatment services to address dental or oral complications after, Medicare-covered treatment of head and neck cancer using radiation, chemotherapy, surgery, or any combination of these.
  • Dental ridge reconstruction done as a result of and at the same time as surgery to remove a tumor.
  • Services to stabilize or immobilize teeth related to reducing a jaw fracture.
  • Dental splints, only when used as part of covered treatment of a covered medical condition such as dislocated jaw joints

To receive reimbursement for these services, there must be proof of “an exchange of information between the physician and dentists” regarding these procedures. It is advised that dentists submit this proof along with the claim with CMS to ensure timely reimbursement for services. Medicare payment can also be made under Part A and Part B for ancillary services and supplies incident to the covered dental services, like:

  • Administering anesthesia
  • Diagnostic x-rays
  • Operating room use
  • Other related procedures
  • I supply oral sleep apnea devices or other covered equipment to Medicare patients, what is my role in Medicare?

A dentist who wishes to receive reimbursement from Medicare for supplying oral sleep apnea devices must enroll as a DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) supplier using form CMS-855-S (PDF). You must maintain documentation for seven years from the date of when this is ordered, which includes the written and electronic documents, the NPI of the ordering practitioners, as well as requests for payments for items of DMEPOS, such as sleep apnea devices. By itself, enrolling as a DMEPOS supplier does not satisfy the requirement for other Medicare-related actions, so a dentist must decide on additional enrollment using form CMS-855-I or CMS-855-O, opting out or doing nothing for other covered services.

  • Document: Step-by-Step Guide – Supplier
  • What if I order imaging services or clinical laboratory services for a Medicare patient? What do I need to do?

You must be enrolled as a Medicare provider in order to receive payment for imaging or clinical laboratory services. The claim form must come from an enrolled provider who is in approved status, along with their National Provider Identifier (NPI). You must maintain documentation for seven years from the date of when this service is order ordered, which includes the written and electronic documents, the NPI of the ordering practitioners, as well as requests for payments for items such as imaging services or clinical laboratory services.

What are my responsibilities?

Paragraph from Nickles Group

Your responsibilities will include:

  1. Maintaining enrollment within PECOS

    Once you enroll in Medicare, you must update any information that might change, whether that be a change in practice location or license number. Failure to do so could result in rejection of claims or deactivation from the Medicare program.

  2. Giving 90 days notice if you wish to no longer participate in Medicare

    If you wish to no longer be part of Medicare due to retirement or surrendering your license, you must provide 90 days notice to CMS. You can withdraw through PECOS, which you used to enroll in Medicare, or you may use a paper withdraw application available here.
How do I enroll as a non-participating provider but still see Medicare patients?

What does it mean to become a non-participating provider?

This means that you will see patients with Medicare, but you will not be included in the directories Medicare provides for its recipients. With this option, you will either be accepting assignment on a case-by-case basis, or you will directly bill your patient. However, if you chose to not accept assignment, a provider is able to charge 115% of the limiting Medicare reimbursement rate.

Also, as a non-participating provider, your claims may not be processed as quickly as those submitted by participating providers.

Becoming a non-participating provider is different from opting-out of Medicare. If you are a non-participating provider, you are limited in what you can charge a patient who utilizes Medicare.

How do I enroll?

  • Step-by-Step Guide – Provider – note there is no section for dentistry

I prescribe sleep apnea treatments to Medicare patients, how does this work as a non- participating provider?

  • Step-by-Step Guide - Supplier

What is covered?

In 2023, CMS began reimbursement for dental procedures that are inextricably linked to, and substantially related and integral to, the clinical success of an otherwise covered medical procedure. Below is a list of procedures they may cover:

  • Dental or oral exams as part of a comprehensive workup prior to the Medicare-covered services listed below, and medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with these Medicare-covered services:
    • Organ transplant, including hematopoietic stem cell and bone marrow transplant
    • Cardiac valve replacement
    • Valvuloplasty procedures
    • Chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, and the administration of high-dose bone-modifying agents (antiresorptive therapy) when used in the treatment of cancer
  • Dental or oral exams as part of a comprehensive workup prior to medically necessary diagnostic and treatment services to eliminate an oral or dental infection prior to or contemporaneously with, and medically necessary diagnostic and treatment services to address dental or oral complications after, Medicare-covered treatment of head and neck cancer using radiation, chemotherapy, surgery, or any combination of these.
  • Dental ridge reconstruction done as a result of and at the same time as surgery to remove a tumor.
  • Services to stabilize or immobilize teeth related to reducing a jaw fracture.
  • Dental splints, only when used as part of covered treatment of a covered medical condition such as dislocated jaw joints.

To receive reimbursement for these services, there must be proof of “an exchange of information between the physician and dentists” regarding these procedures. It is advised that dentists submit this proof along with the claim with CMS to ensure timely reimbursement for services.

Medicare payment can also be made under Part A and Part B for ancillary services and supplies incident to the covered dental services, like:

  • Administering anesthesia
  • Diagnostic x-rays
  • Operating room use
  • Other related procedures

What are my responsibilities?

If you chose to not accept assignment, you may balance bill your patient the limiting fee of 115% of the Medicare fee schedule. Medicare will reimburse the patient of the non-participating provider at 80% of the Medicare fee schedule. You wind up a little over 9% ahead. However, if you chose to accept “assignment” with Medicare and not directly bill your patient, then you would only be able to bill 95% of the Medicare fee schedule directly to Medicare. You will not be able to charge the 115% limiting fee to the patient.

If you are a dentist in the State of New York, state law dictates that you cannot charge more than 5% of the Medicare fee to the patient. This means you are limited to charging 105% of the Medicare fee directly to the patient.

How do my front-desk staff explain this to patients?

  • One-Pager
What if I do not want to enroll in Medicare, and I want to opt-out?

What does it mean to opt-out?

If you want to see patients who are over 65, it is best practice to opt-out of Medicare as you cannot legally bill a patient if they are covered by Medicare.

How do I opt-out?

To opt out of Medicare, you must complete and send an affidavit to each applicable Medicare Administrative Contractor (MAC) that services the state(s) where you practice. CMS has made available a list of MACs by state (PDF). You will need to send it to every Part B entity listed in the state(s) where you practice. Please remember that you are looking for the Part B physician and non-physician provider) addresses, not Part A.

  • MAC Contact List
  • Current Affidavit

If you opt out of Medicare but want to see Medicare-eligible patients, you will have to enter a private contract with each individual Medicare patient.

  • Private Contract Template

Opting out lasts for a two-year period, and a dentist will have to reapply every two years.

  • You can check the CMS database to confirm your opt out status at h ttps://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx

How do my front-desk staff explain this to patients?

  • One-Pager, transparency disclaimer included
What does reimbursement look like if I am a participating provider, a non-participating provider, or if I opt-out?

If the Medicare fee schedule dictates the reimbursement for a a certain procedure is $100, here is how reimbursement would look in any of these scenarios.

If you are a participating provider, the fee schedule would be set at $100. Medicare would pay 80% or $80, and your patient would be responsible for paying $20.00 or $20.00.

If you are a non-participating provider, the fee schedule would be reduced to $95. In this scenario, you can chose to accept assignment or not accept assignment.

If you accept assignment on a case-by-case basis and bill Medicare, Medicare will reimburse you at $76.00 or 80% of $95.00, but the patient would only have to pay the co-pay of $19.00 or 20% of $95.00.

If you do not accept assignment, Medicare will reimburse the patient at $76.00 or 80% of $95. However, you can bill the patient up to $109.25, with the patient paying $33.25 out of pocket. You would make a little more than 9% of the Medicare fee schedule.

If you opt-out, you can charge whatever fee for services; however, it will require a private contract describing the charges for the procedures and affirming the patient understands Medicare will not reimburse them for care from opt-out providers.


Participating Provider

Non-Participating Provider (accepts assignment)

Non-Participating Provider (does not accept assignment)

Opted-out provider

Fee Schedule

$100

$95

$95

None

Medicare Billed

$80

$76

$76

$0

Patient Billed

$20

$19

$33.25

No limit

Total

$100

$95

$109.25

(up to 115% of the non-participating fee schedule)

No limit

 


Frequently asked Medicare enrollment questions

I see Medicaid patients, what do I need to do if I want to see Medicare patients as well?

Because Medicaid and Medicare are managed differently, even if you are enrolled through your state’s Medicaid program, you will need to complete the federal enrollment through the Provider Enrollment, Chain, and Ownership System (PECOS) for Medicare.

  • To enroll, please follow the ADA’s enrollment guide here.
What if I want to see Medicare Advantage patients?

You can see Medicare Advantage patients whether you are enrolled in Medicare or not. Patients who enroll in Medicare Advantage plans have effectively opted out of their care being provided by Medicare, and their care is covered by the private insurer whose plan they have joined. Some, but not all, Medicare Advantage plans have a dental benefit included with their Medicare Advantage plan. These plans operate similarly to an HMO, POS or PPO, and whether you are in that private insurer’s network already will determine whether you are in or out of network for that patient’s Medicare Advantage plan.

If you are a Medicare provider in the network of the insurer whose Medicare Advantage HMO, POS or PPO the patient belongs to, then you must accept the fee you have contracted for, which may be higher or lower than the Medicare allowed fee you would receive if you saw a fee-for-service patient.

There is a caveat -if you have been banned from the Medicare/Medicaid program for any reason, you cannot provide care to Medicare beneficiaries even if they are in Medicare Advantage plans.

  • Medicare Advantage (Part C) Plans

What if a patient is dual eligible for Medicare Advantage and Medicaid? How does reimbursement work for me?

Medicare is traditionally the primary payor for any covered service before Medicaid. However, this only applies to covered services, and many dental procedures are not a covered service unless the procedures are inextricably linked to, and substantially related and integral to, the clinical success of an otherwise covered medical procedure. Therefore, Medicare Advantage plans are not required to pay first if they are aware of a beneficiary that has Medicaid. This means that if you see a Medicare Advantage patient who also has Medicaid, you may receive reimbursement from your state’s Medicaid program, which could be lower than planned.

  • One-Pager for Receptionist

How do I appeal Medicare claim denials?
  • Appeals Process for Medicare Providers

Useful Links and Documents

Other Frequently Asked Questions

  • ADA Policies on Medicare
  • CMS Enrollment Form
  • MAC Contact List
  • Current Affidavit
  • Private Contract Template
  • Appeals Process for Medicare Providers