Medicare Overview
Medicare is a federal 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.
Part A Hospital Insurance: Medicare Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care.
Part B Medical Insurance: Medicare Part B helps cover doctors' services and outpatient care. It also covers some other medical services that Part A does not cover. Medicare Part B does not include coverage for routine dental care. Nonetheless, dentists can find themselves subject to the program’s regulations when they issue prescriptions to their patients enrolled in Medicare or provide some in-patient treatment to hospitalized patients; perform medical treatment, e.g., biopsies; or provide dental treatment in conjunction with cancer treatment.
Part C Medicare Advantage Dental Plans: If you participate with a managed care company that provides dental coverage to patients enrolled in Medicare Advantage Dental Plans, you are advised to review your participating provider contract with your contract attorney to determine whether the panel will provide care to Medicare Advantage enrollees and whether there are any associated enrollment requirements.
Part D Prescription Drug Coverage: Medicare Part D is available to all Medicare recipients. Medicare Prescription Drug Coverage is insurance provided by private insurance companies. Beneficiaries choose a drug plan and pay a monthly premium. Patients covered by Medicare Part D Drug Plans are entitled to benefits for prescriptions issued by their dentists unless the dentist that prescribed the drug is included on the CMS "preclusion list", regardless of the dentist's Medicare provider enrollment status.
Coverage for Sleep-Related Breathing Disorders: Medicare also provides coverage for “durable medical equipment”, including devices fabricated for the treatment of sleep-related breathing disorders.
Dentists that fabricate sleep apnea devices covered by Medicare must be enrolled as a provider of "durable medical equipment" (DME). Dentists that are not enrolled cannot charge patients for this service. Once enrolled, you may choose to "opt-in" or "opt-out" as a DME provider. Enrollment as a DME provider is unrelated to Part B enrollment requirements.
Enrolling in Medicare
Part B Enrollment Options:
Dentists that perform any Medicare Part B Covered Medical Services (biopsies, extractions prior to radiation therapy, etc.), must:
- Enroll in Part B and Opt-In
- Enroll in Part B and Opt-Out
- If you do neither, you cannot charge patients with Medicare for these services.
If you enroll as a Part B provider and "opt-in", you can submit claims for procedures covered by Part B Medicare and agree to accept the Medicare fees as payment in full for these services.
If you enroll as a Part B provider and "opt-out", you cannot submit claims to Medicare and can charge patients your fees for procedures covered by Part B. You must notify your patients that you are not a Medicare provider and obtain a written agreement to charge for these services when you perform a procedure covered by Medicare Part B.
How Do I Enroll?
Information and enrollment forms are available from the Centers for Medicare and Medicaid Services (CMS) or through the regional enrollment contractor. For general information, contact Medicare provider customer service, 866-837-0241.
How Can I Change My Part B Enrollment Status?
Opt-out affidavits signed on or after June 16, 2015, automatically renew every 2 years. If practitioners that file affidavits effective on or after June 16, 2015, do not want their opt-out to automatically renew at the end of a two year opt-out period, they may cancel the renewal by notifying all Medicare Administrative Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.
You and Your Patients
It is advisable for dentists to inform all of their patients that Medicare does not cover dental treatment. In addition, once you have enrolled or opted-out of Medicare Part B, you may wish to include this information with the material given to patients about your practice and billing policies; e.g.: “Medicare does not cover dentistry. Our practice does not participate in Medicare. Nonetheless, if you have a Part D supplemental drug plan, your plan will cover our prescriptions.”
For further information, visit the ADA Center for Professional Success at success.ada.org