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Delaware Health Law Blog

Medicare Enrollment Deadline Looms for Delaware Dentists

Most dentists have never had the need to consider Medicare enrollment, based on the fact that Medicare Part B covers a small amount of dental services (for example, services that are an integral part of a covered procedure and for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw).  But for the many dentists who treat Medicare patients with Part D prescription drug plans, June 1, 2015 marks an important deadline.

Last May, the Centers for Medicare and Medicaid Services (“CMS”) published a final rule that requires dentists to either enroll in or opt out of Medicare in order to prescribe Medicare covered medication to qualifying patients with Part D prescription drug plans. If a dentist does not enroll or opt out, but prescribes such medication to his or her patient, the Part D sponsor or its pharmaceutical benefit manager must deny the pharmacy claim for the drug.  The Part D sponsor or its pharmaceutical benefit manager must also deny requests for reimbursement from patients for a drug prescribed by a dentist that has not enrolled in or opted out of Medicare. CMS has directed dentists to either enroll in or opt out of Medicare by June 1, 2015 in order to ensure sufficient processing time for their patients’ prescription drug claims and to prevent claims from being denied by Part D plans.

While dentists are not billing or receiving payment for prescription drugs, the practical concern is how pharmacies and patients will react.  It is possible that a pharmacy will refuse a prescription, knowing it will be denied payment, or make the patient pay out of pocket.  Patients, then, will suffer a similar denial for reimbursement from the drug plan.  Unfortunately, all fingers will point back to the dentist who prescribed the necessary medication, but who did not enroll in or opt out of Medicare.

When examining the options CMS has provided, “opting out” may seem like the simple solution. However, opting out is not quite as simple as informing Medicare that you are choosing not to enroll.  To become an “opt-out provider,” the dentist must file an affidavit with the regional Medicare Administrative Contractor and enter into private contracts with each patient.  These contracts must meet specific requirements.

On the other hand, dentists may enroll as a “full” provider or as only an “ordering/referring” provider. Enrolling as an “ordering/referring provider” will enable patients to receive coverage for prescription drugs and will also allow colleagues to whom you refer Medicare Part B covered services to receive Medicare reimbursement. Each of these options has different requirements and forms.

The ADA voiced opposition to the rule, noting that this new requirement will affect the majority of dental practices. Delaware dentists should consider their enrollment options and, if prescribing medication to Medicare beneficiaries covered by a Part D plan, submit an enrollment application or opt-out affidavit by June 1, 2015.

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