UPDATE - September 2016
To help you make the best decision for your practice, the ADA hosted a webinar that aimed to:
- Discuss the basic differences between Medicaid and Medicare;
- Highlight the three options available to you so that Medicare patients can receive drug coverage; and
- Provide resources available to assist you in making an informed decision.
The webinar, along with other Medicare resources, is currently available for ADA/VDA members at the ADA Center for Professional Success.
Medicare Opt-in or Enroll Requirement
Over the past two years, dentists and their staffs have been seeking guidance regarding the regulations that require them to either opt-out of or enroll with Medicare and Medicare Advantage. It has been a confusing process and sometimes difficult to find answers but the ADA and VDA have tried to be a helpful resource. The deadline for taking action (either opting out or enrolling) has been extended several times and, as it now stands, the current deadline is January 1, 2019. Below are some answers some of the frequently asked questions that the VDA has received from members. We hope that you find this information helpful.
Frequently asked Questions
Do I have to do something (opt out/enroll) or can I do nothing?
If you do nothing, the patients for whom you prescribe any type of Medicare Part D drug with not be able to use their drug benefit. All of those Medicare patients would be notified that you are not qualified to write them prescriptions. Also, if you have patients with Medicare Advantage plans, you would not be able to bill for any of those services.
What if I opted-out already and now I would like to change my status and enroll?
If you have already officially opted-out, your status cannot be changed for 2 years (unless you contact CMS within 90 days of opting out). For those dentists who opted out before June 16, 2015, you must submit a renewal affidavit to all Medicare Contractors within 30 days after the current opted out period. If you opted out after June 16, 2015, Medicare will automatically renew your status at the 2-year deadline.
How do I Opt-Out?
You must complete an opt-out affidavit form through Palmetto GBA*, which is the entity that administers Medicare in Virginia. You can find the affidavit form by clicking here.
*Providers located in the city of Alexandria and the counties of Arlington and Fairfax are considered part of the Washington, DC Metro area and therefore need to enroll and opt-out with Novitas, a different Medicare Administrator. Click here for information on Novitas opt out and enrollment information.
How can I find my status and/or opt-out expiration?
A list of Opt-out providers is accessible from Palmetto GBA online and can be found by clicking here.
Some other questions have been addressed by Palmetto GBA and can be found on their website here.
For additional FAQs, the Center for Medicare and Medicaid Services (CMS) has information on their website that you can refer to by clicking here.
Background: A final rule was published by the Centers for Medicaid and Medicare Services (CMS) in 2014 that requires practitioners who prescribe Part D covered drugs to be enrolled in Medicare or opt out for those prescriptions to be covered under Part D. This means that neither the practitioner, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private contract is signed between the dentist and the beneficiary that states that neither one can receive payment from Medicare for the services that were performed. The practitioner must submit an affidavit to Medicare expressing his/her decision to opt out of the program. Dentists are included with physicians and other practitioners who are permitted by statute to opt out of the Medicare program.
Medicare is administered by Palmetto GBA in the majority of Virginia and the opt-out affidavit can be found below.
Providers located in the city of Alexandria and the counties of Arlington and Fairfax are considered part of the Washington, DC Metro area and therefore need to enroll and opt-out with Novitas, a different Medicare Administrator. The opt-out affidavit for Novitas can be found below.
If you do not wish to participate with Medicare but prescribe Medicare Part D prescriptions and would like for them to be covered for Medicare-eligible patients, this affidavit form must be completed and submitted to Palmetto GBA or Novitas. By submitting a completed affidavit to opt out of the Medicare Program, prescriptions written by opted out providers will be covered by Medicare. Any testing, such as pathology, will be paid to the laboratory providing the test. A contract is only necessary when a dentist who has opted out of Medicare wants to provide a Medicare service to the patient and forego filing a Medicare claim (by signing the contract, the patient is agreeing to the dentist’s fee). These contracts are not necessary for the patient to have Medicare Part D prescription coverage (patients will be covered as long as the dentist has opted out or enrolled with Medicare). The opt out period is valid for two years at which time the provider must choose to either renew the opt out or enroll. Providers cannot choose to enroll during the opt out period.
The ADA actively opposes this provision and is seeking an exemption for the dental profession. Although the ADA immediately expressed their disagreement and concerns with the rule when it was first announced in May 2014, CMS moved forward with the enrollment or opt-out requirement. On January 13, VDA Executive Director, Dr. Terry Dickinson and ADA Executive Director, Dr. Kathleen O’Loughlin, met with CMS Administrator, Ms. Marilyn Tavenner and this issue was at the top of their agenda for discussion. Further discussion between the ADA and CMS will occur and the VDA will be sure to keep members informed of the outcome.
Additional Information on Medicare Opt Out and Enroll Requirements:
Medicare Flow Chart
Medicare Advantage Question and Answer
Question: Do the Medicare Advantage regulations at 42 CFR 422.220 which specify that an MA plan cannot pay an "opt-out" provider (except for emergency or urgently needed services) also apply to the supplemental benefits an MA plan offers? For example, can a dentist who has opted-out of Medicare under § 1802(b), be paid by an MA plan for the supplementary dental services he or she furnishes an MA enrollee?
CMS Response: A dentist that "opts-out" of Medicare cannot be paid for supplementary benefits offered by an MA plan (other than emergency or urgently needed services as defined in §422.2). The Medicare requirement to not pay an opt-out provider at 42 CFR 422.220 applies to all services provided under or through an MA plan. The definition of "physician" in §1861(r) includes doctors of dental medicine, so if a dentist has one of the affidavits under § 1802(b), the dentist can't be paid by the MA plan for services covered by the MA plan unless those services are emergency or urgently needed services.