The Center for Medicare and Medicaid Services has extended the enforcement date to June 1, 2016, as the day by which dentists must have either enrolled or officially opted out of Medicare in order for prescriptions they write to be covered by Medicare Part D. The recommendation is that dentists submit their application at least 90-120 days before this date to allow sufficient time for processing.
Dentists who treat Medicare eligible patients have three options when delivering dental care to this population. A dentist must do one of the following:
- Enroll as a Medicare provider to bill (covered dental procedures, flu vaccinations, participate in Medicaid managed care)
- Enroll as a Medicare provider to refer and prescribe or
- Opt out of the Medicare program.
“Opting out” is not an option for any provider who treats patients having a Medicare Advantage (MA) dental plan and wishes their patients to receive the benefit from their dental plan. This is true whether the provider is in-network for the plan or not (for PPO-type plans). Remember, if a dentist has already opted out, they can revert their decision within 90 days. Enrolling either using the 855i (provider) or the 855o (to refer and prescribe) are valid options for a dentist treating patients with MA. If a non-contracted dentist enrolls in Medicare using the 855i, this does not mean the dentist is now a MA plan participant (i.e. in-network) for the plan.
MA plans are sold by private carriers (Aetna, Humana, etc.) and often offer routine dental coverage.
A dentist that takes NO action and prescribes medication to a Medicare Part D beneficiary or refers the patient for lab testing/imaging service on or after June 1, 2016, will place an undue burden on his/her patient. By taking no action, the patient will be responsible for payment that would otherwise be covered by Medicare benefits.