UPDATE: Medicare Enrollment Opt In or Opt Out

Molly PereiraFeatured News

By Jennifer Goodrum, CDA director of Government Relations
Dentists who treat Medicare patients must either enroll in the Medicare program or opt out by Feb. 1, 2017. Please note that this requirement applies to the federal MediCARE plans (generally senior and disabled patients) as opposed to the state-based MediCAID plans (for low-income patients). Medicare generally applies to patients over the age of 65, as well as certain adults receiving federal disability payments.

Even though most common dental procedures are not covered under Medicare, dentists are still required to opt-in or opt-out of the Medicare program as a consequence of federal healthcare reform laws. By opting-in or opting-out of Medicare, you will help ensure that tests, procedures, devices and drugs ordered for Medicare patients will be reimbursed, as well as prevent denial of reimbursement for other providers you may refer patients to.
The Medicare opt-in/opt-out requirement was intended to allow the federal government to verify the credentials of all providers—in theory reducing fraud and abuse. However, the requirement is logistically burdensome for certain provider groups, such as dentists, whose services are generally not reimbursed through the Medicare program.
The American Dental Association (ADA) continues to work with the federal government to pursue an exemption from the opt-in/opt-out requirement. H.R. 4062, the Protecting Seniors Access to Proper Care Act, would exempt dentists and other non-physicians who write prescriptions for Part D beneficiaries from the enrollment mandate. At this point, H.R. 4062 has been introduced in the U.S. House, but no further progress has been made on the bill. Prospects for the bill making headway this year are very poor. Most pieces of legislation are not expected to progress in the U.S. Congress in the short term, given the limited congressional schedule in an election year. Given the current compliance date and the time required to process applications, dentists should begin considering opt-in and opt-out options at this time.
In this article, we review the current compliance options. It will be important for each dentist to carefully consider both the benefits and drawbacks of the various program options outlined below. Keep in mind that Medicare states that it takes at least 90 days to process applications. Ideally, any application should be filed by Nov. 1, 2016, to allow sufficient time ahead of the enrollment/enforcement deadline for the government to process your application, whether you elect to opt-in or opt-out.
Opting-In as a Medicare Provider
If you are already enrolled as a Medicare provider, you will not need to take any further action at this time. (Be sure you are a Medicare provider—not a Medicaid provider—as these are two separate systems.)
New Medicare providers have two enrollment options.
1. If you wish to provide and be reimbursed for dental services under Medicare, you may enroll as a treating provider with Medicare. Medicare does not cover most routine dental services but might pay for some diagnostics as well as some dental services for hospital inpatients (see below for additional insight on covered Medicare procedures). Some of the most common covered dental procedures under Medicare are biopsy procedures and sleep apnea devices (though sleep apnea must first be diagnosed by a physician and there are billing nuances to getting this device reimbursed).
You can enroll online using the PECOS system or use paper form CMS 855i.  The Medicare enrollment form is long, but not all sections are relevant to dental providers. Be sure to attach all required documents, sign the certification and mail it to: Novitas Solutions, Provider Enrollment Services, P.O. Box 3095, Mechanicsburg, PA 17055-1813.
Dentists who enroll as rendering Medicare providers should expect to update enrollment information every five years, unless critical enrollment information or status changes prior to that time.
2. Dentists also have the option of enrolling in Medicare as an “Ordering and Referring Provider.” Enrolling as an “Ordering and Referring Provider” is a newer enrollment option that might help bridge the middle ground between enrolling with Medicare as a treating provider and fully opting-out of Medicare. This enrollment option might be a good fit for dentists who do not provide services under Medicare. This enrollment option might also be a good fit for dentists who treat patients who have dental coverage through Medicare Advantage plans and intend to continue billing these plans for services.
Under this option, dentists may not bill or collect payment directly from Medicare or the patient on any services covered by Medicare. As an “Ordering and Referring Provider,” dentists may refer patients to other providers as well as order tests, procedures, devices and drugs—and Medicare will cover the costs of these services for the patient. You will not be paid by Medicare for any services you provide, but other providers you refer to won’t be penalized and your patients won’t be denied access to important medications. Dentists enrolled as “Ordering and Referring Providers” may continue to bill Medicare Advantage plans for care provided to patients, as well as provide dental services not covered by Medicare to patients at a fee agreed to by the dentist and patient. If a dentist enrolls as an “Ordering and Referring Provider” and finds a need to provide a Medicare covered service to a patient, he/she has the following options: 1. enroll as a full Medicare provider prior to rendering care and bill Medicare as appropriate, 2. opt-out of Medicare and enter a formal agreement with the patient to provide the care outside of Medicare reimbursement (see the opt-out information below), or 3. treat the patient without billing the patient or Medicare.
To enroll in Medicare as an “Ordering and Referring Provider,” complete the abbreviated paper enrollment application CMS 855o. The federal government is working to update this form to include a box for dentists to check under the “Physician Specialty” subsection. For now, they recommend using the “Other” category and writing in the word “Dentist.” Once you have completed the form, be sure to attach all required documents, sign the certification and mail it to: Novitas Solutions, Provider Enrollment Services, P.O. Box 3095, Mechanicsburg, PA 17055-1813.
Opting Out as a Medicare Provider
Another option for dentists is to opt-out from Medicare. Before opting-out, be sure that you have thoroughly considered all the implications of this choice. By opting-out, you will be excluded from the Medicare program for two years. You may not apply to be a Medicare provider during this timeframe, even if your employment or patient needs change. You will be unable to submit claims to Medicare or collect payments through Medicare (though there are a few exceptions in emergency care situations ). The opt-out is comprehensive—dentists cannot opt-out only for certain services or patients.
By opting-out of Medicare, Medicare will cover the costs of drugs, tests, procedures and devices ordered for your Medicare patients, as will other providers you refer to—even though you are not a Medicare participating provider. You will not be paid by Medicare for any services you provide, but other providers you refer to won’t be penalized and your patients won’t be denied access to important medications. We realize that this is confusing, but Medicare just cares that you are formally registered with their system—whether you ultimately opt-in or opt-out. As long as you either opt-in or opt-out, your patients and colleagues will not be adversely impacted.
For dentists who choose to opt-out of Medicare, it’s important to note you will no longer be able to bill patients who receive dental care through Medicare Advantage plans, nor receive payment from these plans. Medicare Advantage plans are the supplemental coverage plans typically offered through private insurers such as Aetna, Anthem or Humana. These plans may provide extra coverage for services not routinely offered under Medicare, including dental. If you treat patients who have dental coverage through Medicare Advantage plans and intend to continue billing these patients and plans for services, you will need to consider opting in as an ordering and referring provider or as a full, rendering Medicare provider (see Opting-In as a Medicare Provider above for more information on your enrollment options).
By opting-out of Medicare, you will be required to enter a formal, written agreement (called a Private Contract) with each Medicare patient treated in order to provide a covered Medicare service. This Private Contract must be signed before care is delivered, and there are strict guidelines on what the Private Contract must include. The patient must acknowledge in writing that they are receiving care from a non-enrolled provider and are willing to pay out-of-pocket. The patient must formally agree to give up Medicare payment for services by the dentist and agree to pay the dentist without regard to Medicare’s fee limitations. Log in to the ADA website to access a sample Private Contract form that can be used by your dental office. Only one Private Contract is required per patient during term of the dentist’s opt-out period. The dentist should keep a copy of the signed Private Contract as part of the patient record (Private Contracts don’t need to be submitted to Medicare). After this Private Contract is signed, you may offer a Medicare covered service to a Medicare patient at your usual—or otherwise agreed upon—rate, even if that rate exceeds what Medicare would have reimbursed.
As in all enrollment options, dentists who opt-out from Medicare may continue to provide dental services not covered by Medicare to patients at the fee agreed to by the dentist and patient.
To opt-out from Medicare, visit a state specific Medicare vendor website that provides full instructions on the Medicare opt-out process for Colorado. You will need to choose “Part B” when the website first pulls up, and then accept the end user agreement. (If the form doesn’t pull up directly, select “Opt-Out Listing” under the Enrollment category.)  A sample opt-out affidavit is provided on the Novitas website. You may also log in to the ADA website to access a sample opt-out affidavit form that your dental office can use. If you have technical questions about the opt-out process, contact Novitas at 855-252-8782.
Opt-out affidavits signed on or after June 16, 2015, will automatically renew every two years. If a dentist does not want the opt-out to automatically renew at the end of the two-year period, the dentist may cancel the renewal by Novitas in writing at least 30 days prior to the start of the next opt-out period. Opt-out affidavits signed before June 16, 2015, will expire two years after the effective date of the opt-out. To extend these opt-outs, the dentist must submit a renewal to Novitas within 30 days of the expiration of the current opt-out period. After the first manual renewal, automatic renewals will take effect, as above.
Doing Nothing
If you never see Medicare patients and do not prescribe drugs for Medicare patients, you may elect to do nothing at this time without substantial consequence. This may be an option for certain populations of dentists who truly never see a Medicare patient (such as pediatric dentists), but carefully check your patient mix to ensure that you will not inadvertently affect unusual Medicare classes of patients by your decision.
If you treat Medicare patients and do nothing, these patients will be denied their benefit for any prescriptions you write. Also, if you refer a Medicare patient to specialists, pathologists or other medical providers for covered tests (such as diagnostic radiographs) or medical devices, those providers and services will not be reimbursed by Medicare. This can be a major disruptor to your referral network. Further, if you provide an item or a service that might be covered by Medicare and have not opted-in or opted-out, you must submit a claim on behalf of the Medicare patient and you are not allowed to charge the beneficiary more than the Medicare limit. A dentist might be subject to fines and permanent exclusion from government benefit programs by failing to submit the required bill or charging the Medicare patient more than the maximum Medicare fee.
Please carefully consider your options for complying with the Medicare enrollment requirement and be sure to take appropriate action ahead of the Feb. 1, 2017, compliance date, keeping in mind that it often takes government programs weeks to process applications. Once you have made your decision on opting-in or opting-out and filed the relevant paperwork, you should receive two acknowledgments—one after your application is filed and a final notice by phone or email once the process is complete. You should be able to get application status updates by calling Novitas, Colorado’s Medicare administrator, at 855-252-8782, option 4. Additional resources can be found on the ADA website.


Already, the ADA has been successful in working with the federal government to reduce some of the regulatory hurdles in the Medicare enrollment process. Previously, dentists who opted-in to Medicare as ordering and referring providers were required to revalidate their credentials every five years. Dentists who opted-out were required to resubmit opt-out forms every two years. Both of these revalidation requirements have been removed. Only dentists who opt-in as full Medicare providers are required to revalidate their credentials every five years.

What dental services are covered under Medicare?

Medicare does not cover most routine dental services (and in fact specifically excludes most dental care). Most dental services that are covered by Medicare are covered as a prerequisite to a covered medical procedure for hospital inpatients. Some examples of dental services that may be covered include:
  • Brush biopsy for oral cancer screening
  • Inpatient oral exams prior to renal transplant surgery (but any required treatment is not reimbursable)
  • Extractions when necessary to prepare the jaw for radiation treatment of cancer
  • Procedures that are an integral part of a covered medical procedure (such as reconstruction of the jaw following injury)
  • Procedures that are within the scope of practice for both a physician and a dentist may be provided by a dentist


Sample Case Study:

One of the most recognized dental procedures billed under Medicare is the brush biopsy for oral cancer screening. This is a covered service for a Medicare patient.
Dentist options:
  • Opt-In as a Treating Provider: You would bill for the biopsy through Medicare.
  • Opt-In as an Ordering/Referring Provider: You have perhaps the most flexibility under this option. You would be able to refer the patient to another provider for the biopsy (and that provider would be reimbursed without problem). Alternatively, you could apply to become a rendering provider under Medicare (there is no restriction on changing your status as an Ordering/Referring Provider), opt-out of Medicare and provide the service to the patient pursuant to a Private Contract, or provide the service to the patient at no charge.
  • Opt-Out: You may contract with the patient using a Private Contract to provide the biopsy at your usual or agreed upon fee.
  • Do Nothing: You would be unable to bill Medicare or the patient for the biopsy. If you refer the patient to a Medicare provider for care, that provider would be denied reimbursement based on your referral.