Medicare Enrollment: Should Dentists Opt In or Opt Out?

(August 2014): The ADA News recently published a feature article entitled “Dentists must choose to opt in or out of Medicare enrollment.” (Click here to read that article.) Since then, the GDA has received a number of calls from member dentists on this particular issue. The GDA staff pulled together the following information together from numerous sources to assist members in navigating this confusing Centers for Medicare and Medicaid Services (CMS) requirement.

Much of the information provided here was obtained from the American Dental Association’s “Opting Out of the Medicare Program” and “Medicare Enrollment FAQ” documents, both of which may be found on the ADA’s web site. Members are encouraged to review both documents in their entirety at www.ada.org. Here is a summary of the most important items to remember regarding the Medicare enrollment issue before a dentist makes the decision best for his or her practice:

• Dentists must elect to enroll / Opt-In or Opt-Out and take action by June 1, 2015.

The GDA published an article in the August 2014 GDA Action that incorrectly characterized how a dentist would be affected if they opted out of Medicare and wanted to write a prescription for a Medicare patient. Please note this clarification from ADA.org:

In order for Medicare to pay for prescriptions under Medicare Part D, a dentist must do one of the following: 1) Enroll as a Medicare provider; 2) Opt-out of the Medicare program; or 3) Enroll as an ordering / referring provider. As confusing as this may be, once a dentist is in the Medicare system EITHER by enrolling in OR opting out, their patients are still eligible to receive their Part D prescription drug coverage. However, if a dentist chooses to do nothing and neither opts in nor opts out, any Medicare eligible patients will have their prescription drug coverage denied for the prescriptions a dentist writes.


All dentists must either enroll / Opt-In to Medicare OR Opt-Out, meaning you privately contract with your patient, in order for their Part D prescriptions to be covered.

By signing an affidavit Opting-Out of the program, and entering into a private contract with the patient as appropriate, dentists must remain out of the Medicare program for two (2) years and cannot receive any direct or indirect Medicare payments for services provided to Medicare patients.

Dentists who currently provide and want to continue to provide Medicare covered items must formally enroll using CMS-855 (www.cms.gov) or PECOS (https://pecos.cms.hhs.gov/pecos/login.do). If you do not formally Opt-In, you must formally Opt-Out. Dentists must take one or the other action.

Dentists who do not provide Medicare covered items, BUT who do prescribe drugs for patients with Part D Medicare prescription drug plans, or order covered clinical laboratory services, imaging services, or DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) for patients with Medicare, must either enroll / Opt-In OR Opt-Out. A dentist who chooses to enroll in this instance can use the shorter, CMS-855-O form (www.cms.gov) or PECOS (https://pecos.cms.hhs.gov/pecos/login.do).

Before you decide to Opt-In or Opt-Out, remember that while Medicare generally does not cover routine dental items and services, Medicare MAY COVER certain medical procedures (i.e., a biopsy for oral cancer) or certain dental devices (i.e., sleep apnea devices).

Remember that Medicare Advantage plans often provide Medicare-covered benefits to members and are affected by a dentist’s enrolled / Opt-In or Opt-Out status.

If a dentist elects to enroll with the CMS-855 or CMS-855-O form, remember that it can take 45-60 days or longer for forms to be processed by CMS Medicare enrollment contractors. Take that into account as you look ahead to the June 15, 2015, deadline.

Medicare enrolled providers must adhere to specific record keeping requirements. The ADA’s “Medicare Enrollment FAQ” addresses this issue along with a number of other questions regarding enrollment and opting out.

Answers to Some Commonly Asked Questions About Dentistry and Medicare

Q: What does it mean to be enrolled in Medicare as a dentist?
A: Enrollment means that dentists can be paid for the covered services available to Medicare beneficiaries.

Q: What does it mean to “opt out” of Medicare?
A: Opting out of Medicare means that you cannot receive any Medicare payments for a two-year period and neither the dentist nor your Medicare-eligible patient can submit a claim to Medicare for services. When you opt out, you must privately contract with all Medicare-eligible patients for all Medicare covered services for a two-year period. You cannot opt out for select patients or services; it’s an all-in or all-out process. Opting out requires the dentist to notify the carrier(s) handling Medicare claims in his or her state* that the dentist plans to private contract with Medicare patients. By opting out, a provider is opting out of Part B Medicare (traditional Medicare plans) as well as Medicare Advantage plans (may be referred to as Medicare+ Choice or Medicare Part C).  

Q: How do I opt out?
A: To opt out, dentists must file an Affidavit with each applicable Medicare carrier AND enter into a written “Private Contract” with each Medicare-eligible patient. The ADA published a helpful guide called “Opting Out of the Medicare Program” that explains the process and includes sample Affidavit and Private Contract forms. Find the guide at www.ada.org. By opting out and using Private Contracts, a dentist may charge his or her usual rate for the services rendered. This process needs to be conducted once per two-year Opt-Out period per patient. Affidavits must be filed within 10 days of entering the first Private Contract with a patient and are valid for two years. To renew the Opt-Out status, the dentist must refile an affidavit every two years.

Q: What happens if a dentist who isn’t enrolled or hasn’t opted out orders covered imaging services, clinical laboratory services, DMEPOS, or prescribes Medicare Part D drugs?
A: Medicare will deny the claims submitted by the imaging service, clinical lab, DMEPOS supplier, or pharmacy.

Q: When opting out of Medicare, does each dentist in the practice have to Opt-Out together or can each make their own decision?
A: When a dentist opts out and is a member of a group practice, the organization may no longer bill Medicare or be paid by Medicare for services the dentist provides to Medicare beneficiaries. However, if the dentist continues to provide the practice the right to bill and be paid for the services provided by that dentist to Medicare patients, the organization may bill and be paid by the beneficiary for the services that are provided under the private contract. The decision of one dentist within the group to opt out of Medicare does not affect the ability of the group practice to bill Medicare for the services of those dentists within the practice who have not opted out of Medicare. If every dentist within the group practice or corporation opts out, then such practice or corporation would have, in effect, opted out. (www.aaoms.org.)

Q: Can our office Opt-Out of traditional Medicare without opting out of Medicare Advantage / Medicare Managed Care plans? Also, if we are contracted with Medicare and not contracted with any of the replacement plans, what is my obligation in terms of Medicare fee schedule/patient responsibility, etc.?
A: When opted out of traditional Medicare, dentists are not entitled to Medicare or Medicare Advantage (MA) reimbursement. It is the traditional local Medicare carrier's responsibility to notify the MA plans that the doctor has opted out. If opted out of traditional Medicare you would have to privately contract with MA patients as well.

If one remains a Medicare provider and is not contracted with a Medicare Advantage (MA) plan, the doctor may possibly be prohibited from treating MA patients or from collecting more than the traditional Medicare private fee-for-service allowed amount. For instance, patients covered by Medicare HMOs are restricted to dentists within the MA HMO network. Patients covered by Medicare PPOs may see any dentist they like, however some incur higher out-of-pocket expenses if they see a dentist out of the network. Some Medicare PPO's may reimburse non-contracting providers only the original Medicare rate.

Medicare Advantage fee-for-service plans are permitted to establish their own fee-schedules and balance-billing rules, which, in some cases, differ from original Medicare payment rates and balance-billing rules. There are no formal provider contracts with MA fee-for-service plans, therefore if a dentist knowingly treats a MA fee-for-service patient, the dentist may be considered a "deemed" provider. Meaning the payment would be similar to that of the payment for traditional Medicare fee schedule for participating and non-participating providers.

Dentists treating enrollees of a MA plan will need to carefully examine the type of MA plan as well as the fee-schedule and balance billing rules with each plan to decide if the terms and conditions of participation warrant a decision to treat and be "deemed" a contracting provider.

Finally, if a dentist is not enrolled in traditional Medicare, he or she may not treat MA patients since Medicare Advantage is a Medicare product. It is advised that those dentists who take emergency call enroll in Medicare for the purpose of receiving an active provider number to obtain Medicare or MA reimbursement for emergency services rendered. (www.aaoms.org.)

*GEORGIA Medicare Administrative Contractors (source: www.cms.gov)

Part A and Part B Medicare Administrative Contractors
Jurisdictions 10: Cahaba Government Benefit Administrators, LLC

Part A:
Georgia Part A Medical Review
PO Box 830867
Birmingham, AL 35283-0867

Part B:
Georgia Part B Medical Review / ADS
PO Box 830050
Birmingham, AL 35283-0050
www.cahabagba.com
(877) 567-7271
Accepts esMD transactions

Medical Review Jurisdiction C
CGS Administrators, LLC
PO Box 20010
Nashville, TN 37202
ngs.cedihelpdesk@wellpoint.com
http://cgsmedicare.com/jc/index.html
(866) 270-4909
Accepts esMD transactions