UPDATE: Medicare Regulations Delayed
Regulations Delayed Until February 1, 2017 -
When it comes to Medicare, you may be trying to decide whether to enroll or opt-out. Finding out how to enroll in or opt-out of Medicare can be one of the most complex and frustrating issues dentists face.
CMS urges prescribers to submit their Medicare enrollment applications or opt out affidavits to their Medicare Administrative Contractors as soon as possible (generally by August 1, 2016); however, enforcement of this rule has been delayed until February 1, 2017 (READ MORE).
The American Dental 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.
The simplest primer the ADA came up with is a very short video tutorial (VIEW NOW).
The video goes through three basic questions that will easily help you make a decision:
- If you provide Medicare covered services (very few services covered) – Enroll using 855i
- If you participate or treat Medicare Advantage patient – Enroll using 855i OR 855O (855O is much simpler and that seems to be the option most dentists are choosing. Additionally CMS encourages you to use the 855O if you aren’t actually providing Medicare covered services)
- If you order/refer for lab services, durable medical equipment (DMEPOS) OR supply sleep apnea devices – Enroll using 855O OR simply opt out.
Here are articles on a few of the most commonly asked questions regarding enrolling and opting out of Medicare.
Below is also information on how to submit the forms to enroll/opt-out.
For dentists practicing in the state of Kansas,
send all enrollment/opt-out forms to:
Wisconsin Physicians Service
Provider Enrollment Unit
P.O.Box 8248
Madison, WI 53708
Phone: 866-518-3285
Enrollment
Use CMS Form 855I to Opt-in as a Medicare provider. Use CMS Form 855O to register in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries.
Before enrolling in Medicare, you must have a National Provider Identifier (NPI). While most dentists already have an NPI, there may be a few who do not. You again have the option of submitting a paper NPI (CMS Form 101114) or going on line. You may file the form on line by going to: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
For the necessary addresses to send your Medicare provider application (if you are a dentist not practicing in Kansas), please follow this link: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf.
You’ll need to send it to every Part B entity listed in your particular state. Please remember that you are looking for the Part B (physician and non-physician provider) addresses, not Part A.
Opt-Out
A dentist must follow certain steps to formally opt out of Medicare. If you are considering opting out of Medicare, please read the following information before making your decision. We provide a sample affidavit that you can use to opt-out of the program and a private contract that you can use if you choose to provide Medicare covered services to your Medicare-eligible patients after you have opted out.
Dentists may elect to opt out of the Medicare program and provide Medicare-covered services by entering into written “Private Contracts” with their Medicare-eligible (generally, senior and disabled) patients and by filing an Affidavit with each applicable Medicare carrier.
Although routine dental services are not covered by Medicare Part B, there are several reasons why a dentist may wish to opt out of the program. For example, dentists may choose to opt out of Medicare as an alternative to enrolling as an ordering/referring provider under the June 26, 2012 interim final rule regarding changes in provider and supplier enrollment. Also, dentists who provide Medicare-covered services (there are a few dental procedures covered by the program) may elect to opt out of Medicare and enter into Private Contracts with patients who are Medicare beneficiaries.
To help ADA members understand the opt-out rules, the ADA has prepared this article and the accompanying model Private Contract and Affidavit, as a member-only service. For more complete information about opting out of Medicare, contact your state’s Medicare contractor and see Chapter 40 of the Medicare Benefits Policy Manual (PDF).
Medicare Advantage
Medicare Advantage Plans provide Medicare-covered benefits to members, and sometimes offer extra benefits that original Medicare doesn't cover, such as dental services. You must enroll in Medicare in order to prescribe drugs covered by a Medicare Advantage plan (you can use either enrollment form – 855i or 855o). If you opt out of Medicare, you may not receive reimbursement from a Medicare Advantage plan.
In a conversation with CMS, the ADA confirmed that “opting out” is not an option for any provider who treats patients in a Medicare Advantage plan and wishes their patients to receive the benefit from the MA plan (detailed information on this appears after my signature below). This is true whether the provider is in-network for the MA plan or not (for PPO-type MA plans). The MA organization is required to check the opt out list on a regular basis. Remember if a dentist has already opted out they can revert their decision within 90 days.
If a non-contracted dentist enrolls in Medicare using the 855i this does not mean the dentist is now an MA plan participant i.e. in-network for the MA plan.
