This decision tree should help you decide if you want to opt
in for Medicare. If you write prescriptions for patients on
Medicare, you should consider the opt in option. Go to the
ADA web site to click on Medicare links for more information.
Option 1:
Enroll in
Medicare using form
CMS-855I.
2
Option 1:
Enroll as a Medicare
Ordering/Referring Provider
using form CMS-855O.
5
Option 2:
Formally
opt out of Medicare.
3
Option 2:
Formally
opt out of Medicare.
3
Do you provide services covered by Medicare?
1
Do you order or refer patients for Medicare covered
clinical laboratory services, imaging services, or DMEPOS
4
?
• Do not provide any services covered
by Medicare
• Do not order or refer patients for
Medicare covered clinical laboratory
services, or DMEPOS.
However
, as of December 1, 2015, if you have not enrolled
or formally opted out, and you prescribe a drug covered by
a Medicare Part D plan, the Medicare plan will not pay for
the drug. Similarly, dentists must enroll in order to prescribe
drugs covered by Medicare Advantage plans (note that
dentists who opt out of Medicare cannot submit claims
to Medicare Advantage plans). Dentists must submit a
Medicare enrollment application or opt-out affidavit by
June 1, 2015 to ensure sufficient processing time to avoid
their patients’ prescription drug claims from being denied
by their Part D plans beginning December 1, 2015.
YES
NO
YES
NO
You do not need to enroll in Medicare
or formally opt out if you:
Should I Enroll In Medicare?
1
Dental services covered by Medicare.
Medicare covers a very limited number of dental services,
such as the extraction of teeth to prepare the jaw for radiation treatment, or an oral exam performed
on an inpatient basis prior to renal transplant surgery (see CMS,
. However,
certain biopsies performed in a dental office may be covered by Medicare.
How do I know whether a patient is on Medicare?
Medicare is a health insurance program for
people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-
Stage Renal disease. You can only find out whether a patient is on Medicare by asking the patient or the
patient’s legal representative.
2
Form CMS-855I.
You can use the paper or electronic form (see CMS,
).
What if I’m already enrolled, but as a DME supplier?
If you also provide covered services, you must also enroll using CMS-855I.
If you order/refer but you do not provide covered services, you must enroll using form CMS-855O (you may also use CMS-855I).
3
Opting Out.
Opting out requires you to file an affidavit with all applicable Medicare contractors and enter into private contracts with patients who are Medicare
beneficiaries. Opting out lasts for two years. (see ADA,
and
, CMS,
(PDF). Note that dentists who opt out of Medicare cannot submit claims to a Medicare Advantage plan or receive reimbursement
from Medicare for covered items such as sleep apnea devices.
4
Ordering and referring.
For example, some oral pathology services are covered clinical laboratory services, and in some cases oral sleep apnea devices may be
covered DMEPOS. Medicare will not pay for the clinical laboratory or imaging service or the DMEPOS if the ordering or referring dentist is not enrolled or formally
opted out. For more information, see CMS,
PDF).
5
Form CMS-855O.
You can use the paper or electronic form (see CMS,
). Note: If you only order/refer, you may choose to enroll as a
Medicare provider using the longer form CMS-855I, but that offers no advantage if you are not seeking to provide Medicare covered services.
Medicare Decision Tree: Reprinted from the ADA Website.
