CMS changes rules so Medicare Advantage plans can pay dentists who have opted-out

Beginning Jan. 1, the Medicare opt-out status no longer applied to supplemental dental services covered by dental insurance companies through Medicare Advantage plans.

“Medicare Advantage providers and/or patients will now be able to receive payment from Medicare Advantage plans for services even if a provider has opted out of Medicare,” said Mark Johnston, D.D.S., chair of the Dental Benefit Information Subcommittee of the Council on Dental Benefit Programs. “This is a huge win for the ADA which had been advocating to get this rule changed for a long time.”

The previous version of the rule stated that if a provider opted out of Medicare, neither the patient nor the provider would get paid by a Medicare Advantage plan except for emergency or urgently needed services.

“The old policy placed a burden on dentists who had opted-out because the opt out period lasts two years and cannot be terminated early unless the dentist is opting out for the very first time and terminates the affidavit no later than 90 days after the effective date of the dentist's first opt out period. This risked presenting access issues for this patient population and has long been problematic,” said Dr. Johnston.

The opt-out provision is still in effect for services covered under original Medicare. This rule did not rescind the need for ordering/referring providers to be enrolled in Medicare for pathologists to get paid by Medicare when performing a biopsy, for example. The pathologist will not be paid by Medicare unless the referring provider has enrolled in Medicare to provide covered services using CMS form CMS-855-I, enrolled in Medicare to order and refer using CMS form CMS-855-O or formally opted-out. The same is true for ordering imaging services and durable medical equipment, prosthetics, orthotics and supplies.

The CMS website has not yet been revised to include the new opt-out rules.

The ADA will host a webinar on Medicare Advantage and dentistry on April 26 at noon CT. The continuing education credit is pending.

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