Medicare resources are available on the ADA website.
Treating Patients Enrolled in Medicare Advantage Plans
When treating a patient covered by Medicare, it is important to know the rules determining whether you will be reimbursed for providing services. Medicare covers dental care only in limited circumstances. Dentists can be paid by Medicare if they perform medical services covered under Medicare Part A (hospital) or Medicare Part B (medical) as long as they have enrolled as a Medicare provider (there are different forms for Medicare enrollment so you must be sure you use the correct form). Covered services include biopsies, the extraction of teeth to prepare the jaw for radiation treatment, and an oral examination performed on an inpatient basis as part of a comprehensive exam prior to renal transplant surgery or performed in a federally qualified health center prior to a heart valve replacement.
Medicare Advantage plans (Medicare Part C) offer supplemental benefits through private insurance carriers. Supplemental benefits can include dental and vision, which are not typically covered under original Medicare. Dentists are now seeing an increase in patients who are enrolled in Medicare Advantage plans. According to the National Association of Dental Plans, 51% of Medicaid-eligible individuals are expected to enroll in a Medicare Advantage plan by 2030.
If you have not filed a Medicare opt-out affidavit with a CMS Medicare Administrative Contractor (MAC),* you will receive payment from Medicare when treating enrolled patients. However, if an opt-out affidavit was filed, you will not be reimbursed by Medicare and your patients will be unable to receive reimbursement from their plan as well. Your patients should be told prior to treatment that you are not a Medicare provider and they will be responsible for your full fee.
If your opt-out affidavit was filed prior to June 16, 2015, it will automatically renew every two years. Dentists who do not want their opt-out to renew at the end of a two-year period must cancel the renewal by notifying, in writing, all MACs with which they filed an affidavit at least 30 days prior to the start of the next opt-out period.
Dentists can determine whether they have opted-out of Medicare and when their opt-out affidavit expires at: https://data.cms.gov/Medicare-Enrollment/Opt-Out-Affidavits/7yuw-754z.
For additional information about Medicare, visit CMS.gov
* The Medicare Administrative Contractor in New York State is National Government Services.