Saturday, May 16, 2015

UPDATE! Medicare Enrollment: Opt In or Opt Out?

Recent changes in some of the rules regarding Medicare will now affect dentists more than they previously have.   Thanks to a recent visit with Aaron Fisher of HealthChoice, we learned a few things about these changes effective June 1, 2015.

The number of participating doctors in Medicare is remarkably low.  That is understandable, since "Medicare doesn't cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices."  source

However, Medicare will begin offering supplemental dental insurance to Medicare participants through 3rd party insurance companies. These are known as Medicare Advantage Plans.  In other words, Medicare is offering private dental insurance through private dental insurance companies.  Here's the catch... The federal government gets to set the fee schedule.   So if you want to participate in the the medicare advantage plans, through any given provider, you have to be willing to take the federal fee schedule.

So before you sign up for the Medicare Advantage Plans, you need to review the fee schedule, as you would any other dental PPO fee schedule, and decide if it makes business sense to work at the discounted fee schedule.  If you are in Arizona, the easiest way to describe these plans would be "AHCCCS for Medicare Patients".  The fee schedule would be the same as the AHCCCS fee schedule.

A quick example of some commonly billed codes on the AHCCCS fee schedule.
  • D0150 Comprehensive Exam - $38.33
  • D0210 Full Mouth Series - $66.02
  • D1110 Adult Prophy - $46.71
  • D2392 2-Surface Posterior Resin - $82.10
  • D2792 Noble Crown - $514.70
  • D3330 Molar RCT - $507.48
For a full fee schedule, click here.

The ADA Benefit Plan Analyzer may be a useful tool in helping you decide what impact Medicare participation, as well as any other PPO, will have on your practice. click here.

So if you decide to participate in the Medicare Advantage Plans, you will be agreeing to this fee schedule like any other PPO that you would sign up for.  There may be some benefits with some of these plans.  Since these plans are administered by a 3rd party, they may have less paperwork than you would expect from a government program, less pre-authorization needed and may have higher benefit levels than the typical $1000-$1500 benefit level of most dental benefit plans.

However, EVEN if you decide NOT to participate in Medicare Advantage plans, you can still be affected by the new laws.  Here's how...

If you order or refer covered clinical laboratory services (biopsies), imaging services, or DMEPOS (apnea devices) for Medicare patients you will need to either enroll in Medicare or formally "opt out" of Medicare.  For more information, click here.

As of Dec. 1, 2015, Medicare will require all physicians, including dentists, who prescribe Part D covered drugs to their patients to either be enrolled in Medicare OR must "opt out" of Medicare, in order for their patient's prescriptions to be covered by Part D.

Doctors who "opt out" of Medicare are required to have written contracts with the Medicare beneficiary stating that the doctor and the patient have forfeited the right to bill Medicare, and the patient is essentially paying a "fee for service" out of their own pocket.  The doctor must also submit an affidavit to Medicare expressing their desire to "opt out" of the Medicare program.  This "opt out" affidavit is for a period of 2 years.  So while all dentists are free to participate in Medicare, there are new compliance issues if you choose not to participate.

So to summarize:
  • Dentists who want to be a part of Medicare Supplemental Dental Plans should enroll in Medicare using form CMS-855I
  • Dentists who want to be able to order lab services (biopsy), imaging services or DMEPOS (apnea appliances) covered by Medicare need to enroll with shortened form CMS-855O. Dentists who want to are not Medicare providers, but want their patient's prescriptions to be covered by Medicare Part D, can also use for CMS-855O.
  • Dentists who want to be able to order lab services (biopsy), imaging services or DMEPOS (apnea appliances) but DO NOT want to use Medicare benefits must "Opt Out" by:
    • Sending Medicare an affidavit stating they are not participating in the Medicare program - you have 90 days to change your mind - otherwise there is a 2 yr waiting period before you can sign up.  This "opt-out" option will expire after 2 yrs and will need to be done again.
    • Signing contracts with Medicare patients stating that both parties forfeit the right to bill Medicare - essentially agreeing to pay a "fee for service"
    • Dentists who "opt out" of Medicare DO NOT need a contract with the patient for them to recieve their Medicare Part D prescriptions.  Contracts with patients are only needed when you are providing other services that would normally be covered by Medicare.
  •  Dentists who do not want to participate in any Medicare services, but still wish for their patient's prescriptions to be filled by their Medicare Part D need to formally "opt out" by sending Medicare the affidavit.
  • Dentists who do not provide any Medicare services, who do not order or refer Medicare services (lab, imaging, DMEPOS) and who do not need Medicare Part D to cover the prescriptions they write for their patients do not need to enroll or "opt out"
 The deadline for dentists to "opt in" or "opt out" of Medicare is June 1, 2015.

Those dentists who don't take any action will not likely see many changes this year, but eventually will begin to get calls from the pharmacy or patients complaining that the medications they have prescribed to their patients are not covered by Medicare Part D.  According to the ADA, complying with this law will save you time and aggravation.

The following infographic, published by ADA, will help you decide whether to "opt in" or "opt out" of Medicare.

The clearest explanation that I have seen is with a video tutorial on the ADA website for ADA members.  click here

For more information from the ADA News, click here.

The Arizona Dental Association has recently published another summary that is very helpful.  Click Here

Sources/More Info
Medicare Enrollment FAQ
Information about "Opting Out"
Enrolling with Medicare for ordering and referring only

A special thanks to the endoblog guest editor, Dr. Morris Oswald of Red Canyon Dentistry