Information for Dentists
Medicare Rule on Prescription Drug (Part D) Coverage
The Centers for Medicare & Medicaid Services has announced it is delaying enforcement of the Medicare Part D prescriber enrollment requirement. Providers now need to enroll by Jan. 1, 2019 instead of by Feb. 1, 2017 as previously reported.
Effective January 2, 2019, Medicare Part D enrollees will not receive benefits for otherwise covered medications if prescriptions are written by dentists who are not enrolled in, or have not opted out of, the Medicare program.
Watch a Medicare Tutorial on the ADA Website. (Member log in required).
Although the Medicare program does not cover routine dental services, the advent of Medicare Advantage plans now allows patients to receive dental coverage through supplemental insurance. As a result, if you opt in using form 855o for prescription coverage only, or submit an opt out affidavit, you will not be able to submit for reimbursement of dental procedures through these supplemental plans. Additionally, if you do nothing, your patient will be denied prescription coverage and you will not be reimbursed by these supplemental plans.
Although the Medicare program does not cover routine dental services, there are some limited exceptions; notably surgical biopsies and dental treatment integral to a covered medical service. Dentists may consider the following before choosing to enroll in or to opt out:
For example, some New Jersey dentists have enrolled as a Durable Medical Equipment (“DME”) provider only, so that Medicare benefits can be paid for sleep apnea appliances; however, enrollment as a DME provider alone is not sufficient for patients to receive coverage for prescription drugs.
In addition, some commercial HMOs offer “Medicare Advantage” plans to eligible individuals as an alternative to traditional Medicare, and some of those plans cover dental services not usually covered; some New Jersey dentists do participate in these networks but have never enrolled in the traditional Medicare program.
To Enroll in Medicare
To enroll in Medicare, an application from a dentist in New Jersey must be submitted to the Medicare Part B administrative contractor in Jurisdiction L, Novitas Solutions, Inc:
Novitas Solutions, Inc.
Provider Enrollment Services
P.O. Box 3157
Mechanicsburg, Pennsylvania 17055-1836
T: (877) 235-8073
For a paper copy of the enrollment form, click: cms855i
To access the internet-based Provider Enrollment, Chain and Ownership System (PECOS) click here.
To Enroll in Medicare for Prescriptions and Referrals
Rather than opting in completely to Medicare, you can simply opt in for prescriptions and referrals to help your Medicare patients.
To do this, use cms855o
instead of 855i.
To Opt Out of Medicare
To opt out of Medicare, a dentist in New Jersey must submit a Medicare Opt-Out Affidavit to the Medicare Part B administrative contractor in Jurisdiction L. That contractor is Novitas Solutions, Inc., telephone (877) 235-8073.
Click to access the Novitas preferred Opt_Out_Affidavit
. NOTE: if you have NEVER opted in to Medicare, fill in N/A where the form asks for the Provider Transaction Access Number (PTAN). If you are currently opted-in and would like to opt-out, you will find your PTAN on the letter that was sent by your MAC when your enrollment in Medicare was approved.
Mail this form to:
Provider Enrollment Services, ATTN: Opt Out,
P.O. Box 3157
Mechanicsburg, PA 17055-1836
Please note that if a dentist opts out, he/she will have to enter into a private contract with each Medicare beneficiary, but only if Medicare-covered services are being provided. Click sample_opt_out_contract
for sample wording.
For Frequently Asked Questions about the Medicare Opt In/Opt Out process, visit the ADA website (member log in required).