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Medicare Opt-Out

As we reported in the February 2016 issue of The Root, the Texas Dental Association’s legislative department continues to receive calls from members regarding Medicare opt-out. As of June 1, 2016, Medicare Part D plans will no longer cover prescriptions unless you (1) enroll in Medicare, (2) enroll as an ordering-referring provider, or (3) opt out. Details about the available options for dentists as well as electronic links to applicable forms are available on the TDA website. To learn more, visit tda.org and select Advocacy > Regulations > Regulations Spotlight

For dentists to meet the June 1, 2016 effective date, they must submit their application to the Centers for Medicare & Medicaid Services (CMS) by March 1, 2016, to allow sufficient time for processing.

Three Options for Dentists

Option 1) Enroll in Medicare. This can be done by completing paper form CMS-855I and mailing it to Texas’ Medicare Administrative Contractor (MAC), or, by CMS’ internet Medicare Provider Enrollment, Chain, and Ownership System (PECOS)

Option 2) Opt in as an ordering/referring provider. Dentists prescribing potentially covered medications should enroll as an ordering/referring provider. Also, if the dentist orders and refers other services such as laboratory, imaging, or DMEPOS (durable medical equipment, prosthetics, orthotics and supplies supplier) services, and isn’t enrolled to order and refer services, those potentially covered services will be denied. Dentists wishing to enroll strictly as an ordering/referring provider must complete form CMS-855O and mail it to Texas’ MAC.

Texas Medicare Administrative Contractor
Novitas Solutions
JH Provider Enrollment Services
PO Box 3095
Mechanicsburg, PA 17055-1813
855-252-8782, Option 4
www.novitas-solutions.com

Option 3) Opt out of Medicare. Dentists may elect to opt out of the Medicare program and still 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 Texas’ MAC. To find the opt-out affidavit and private contract forms, visit the American Dental Association’s Center for Professional Success and search “Resources for Opting Out of Medicare.” 

Dentists cannot sign private contracts with Medicare beneficiaries in need of emergency or urgent care services. Dentists cannot selectively opt out of Medicare for some Medicare beneficiaries but not others, or for some services and not others. 

Opt-out affidavits filed after

June 16th, 2015, automatically renew every two years. Affidavits submitted before this date will need to be re-submitted after the two-year period expires. 

Frequently Asked Questions

I opted out and now I want to opt in. How do I do that?
Complete the opt-in process at least 30 days before your automatic opt-out renewal date.

What about Medicare Advantage Plans?
A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide subscribers with all Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.

Dentists opting out of Medicare cannot be paid for supplementary benefits offered by a Medicare Advantage (MA) plan (other than emergency or urgently needed services as defined). To be clear, Medicare will not pay for services provided under or through an MA plan by a dentist provider who has opted out of Medicare.

I am not sure whether I enrolled in Medicare. Is there a way to check?

Yes. Visit www.novitas-solutions.com and select Jurisdiction H > Set Preference for Part B > Quick Links (upper right corner) > Opt-Out Listing.

Tips

Section 4 on CMS-8550.

  • In Section 4 under physician specialties, CMS lists entries for “Maxillofacial Surgery” and “Oral Surgery (Dentist only)” as well as an “Unlisted or Undefined Physician Type” which requires an additional entry. CMS suggested that dentists, including specialists other than oral surgeons, select “Oral Surgery (Dentist only).” However, if a dentist is an Oral and Maxillofacial Surgeon, they should select “Maxillofacial Surgery.”

Medicare & Sleep Appliances

  • First, the dentist must be either enrolled in Medicare or enrolled as an ordering/referring provider.
  • Second, the dentist must complete a separate CMS form—8555—to enroll as a DMEPOS. There is also an enrollment fee of $553 to enroll as a DMEPOS provider.
  • When completing the 855S form section 3 D. Products, sleep apnea devices can be orthoses: custom fabricated.
  • Under Section 3 A. Type of supplier, choose the physician/dentist category.
  • Dentists are not limited to oral surgeons under the 855S form.