Medicare Requirements

Medicare generally does not cover dental services. In fact, Medicare Law expressly excludes “…services in connection with the care, treatment, filling, removal or replacement of teeth or structures directly supporting teeth.” A narrow exception permits coverage of dental services that are necessary for a covered procedure (such as jaw reconstruction following accidental injury). In addition, extractions of teeth necessary to prepare the jaw for radiation treatment of cancer (i.e., NOT in preparation for dentures) are covered. 

Medicare may also cover certain medical procedures that dentists are licensed to perform (for example, a biopsy for oral cancer).

If you do not take action to register with the Medicare program:

• Your Medicare eligible patients will have their prescription drug coverage denied for any prescriptions you write.
• Medicare will deny claims submitted by imaging services, clinical labs, or other dental specialists if you have ordered those services. 

Case in point: Dr. Douglas Arendt, an Oral and Maxillofacial Pathologist in Virginia closed his practice because he’s taken a loss on so many cases referred from other dentists who were not registered with the Medicare program. Dr. Arendt’s story was highlighted in the June 16, 2014 issue of the ADA News.

In order for prescriptions or services to be covered by Medicare for your eligible patients, you must take one of three actions:

1. Enroll as a Full Medicare Provider
2. Enroll as an “Ordering/Referring Provider”
3. Opt-Out of Medicare

Option #1: Enroll as a Medicare Provider

• By becoming a Medicare provider, you are authorized to bill and receive payment for the covered services you provide to Medicare beneficiaries;
• You are obligated to submit a claim form on behalf of the Medicare beneficiary if you provide an item or service that may be covered by Medicare;
• You are not allowed to charge the beneficiary more than the applicable Medicare limits on charges (no balance billing);
• You will be required to report data on quality measures or be subject to a 2% negative payment adjustment for covered professional services;
• Complete form CMS-855-I.

Option #2: Enroll as an “Ordering/Referring Provider”

• This is appropriate only if you do not provide Medicare covered services, but you want to enroll ONLY to order services or write prescriptions for Medicare Beneficiaries;
• Complete a simplified Medicare enrollment form CMS-855-O;
• One time application; status as “ordering/referring provider” is effective until you terminate it;
• Prescriptions you write will be covered for patients under Medicare Part D; other providers will receive payment for services.

Option #3: Opt Out of Medicare

• Allows dentist to charge usual, or otherwise agreed upon rate, even if it exceeds what would have been reimbursed by Medicare;
• Must Opt Out every 2 years;
• Dentist can receive NO Medicare payments for 2 years, and neither the dentist nor the patient can submit a claim to Medicare during that 2 year period;
• Provider must file an affidavit with all of the carriers handling Medicare claims in their state (1 in CT)
• Dentist must privately contract with all Medicare eligible patients for all Medicare-covered services for the 2 year period before services are delivered.

A number of resources are available to members to assist in deciding which option may work best for your practice, and once that decision is made, access to the appropriate forms and documents necessary to take the appropriate action. 

In addition, the ADA’s Center for Professional Success has a great deal of information, including frequently asked questions and links to CMS documentation to help members navigate these sometimes confusing waters. Go to success.ada.org and search “Medicare” for access to these great resources.

• Medicare Decision Tree
  
• ADA Center for Professional Success resources on Medicare
• Accessing and Where to Send Medicare Forms (PDF)

Opt-Out Resources

• Opt-Out Affidavit
• Sample Opt-Out Contract (PDF)
• Sample Opt-Out Letter to Patients (doc)

Ordering/Referring Resources

• CMS-855-O Form 
• Ordering/referring Provider Fact Sheet

Medicare Enrollment

• Medicare Enrollment (CMS-855-I) (PDF)
• Physician Quality Reporting System (PQRS)
• CSMS Medicare quality webinars are available on demand (click here to view all the webinars in PDF or .wmv file format)