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To Opt-In or Opt-Out: What Every Dentist Needs To Know About Medicare

Feb 25, 2021

If your practice treats patients over 65, the CMS has given you a reprieve by delaying the enforcement deadline of the Medicare Opt-in/Opt-out program from June 1, 2015 to June 1, 2016. Regardless of the deadline date, the CMS final rule could mean serious changes for your practice.

On June 1, 2016, the way both you and your patients interact with Medicare will shift. Below are listed your options and the implications of your choice of action (or inaction):

If You Opt-In

If you’re one of the 3 to 4 percent of the 186,000 practicing dentists who were enrolled as a Medicare provider and decided to continue by opting-in, business will go on as usual for you. The program covers a limited number of dental procedures. According to an article on

“Medicare will reimburse dentists for dental services that are an integral part either of a covered procedure, such as reconstruction of the jaw following accidental injury or disease, or that are for extractions done in preparation for radiation treatment for neoplastic diseases that involve the upper or lower jaws.

Medicare will also reimburse dentists for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under specific circumstances. These oral examinations would be covered under Part A if performed by a dentist on the hospital's staff or under Part B if performed by a dentist after these diseases have been diagnosed by a physician.”

If You Opt-Out

If your practice has opted-out of Medicare enrollment (which only means you opt-out of your right to bill Medicare and can charge patients what you like, not that you are free from Medicare altogether), then your office will no longer receive reimbursement for services covered by Medicare. Opting-out, however, does not mean your patients won’t need or request services that Medicare does address.

If you have a patient who would like to receive a Medicare-covered service, who fully understands that you’ve opted out of the program, and is willing to pay out of pocket, then you should enter into a private contract with the patient, according to the ADA. This private contract arrangement does not apply to patients who are eligible to receive Part D reimbursement for prescription drugs (who do not need a contract).

Additionally, you’re eligible to treat patients with private dental benefit plans that are not Medicare Advantage plans even if you have opted out. However, if the patient does have a Part D prescription drug plan, you will need to either:

  • Be enrolled as a Medicare provider
  • Have opted-out of the Medicare program
  • Be enrolled as an ordering/referring provider

Keep in mind that your decision to opt-out keeps you locked out of Medicare reimbursement for a period of two years (after which you’ll need to go through the process again).

If You Don’t Make A Choice

If you choose to do nothing, that is not opt-in or opt-out, you will put your patients at risk of having any prescription you write rejected.

Of course this sounds bad on its face, but the implications go even deeper. Not making a decision means you are unable to create fully actionable treatment plans for your patients. As patients realize what’s happened to your service levels, your retention numbers could undoubtedly drop and you could expect to see fewer referrals from both patients and other providers, such as pharmacies, as word spreads.

Pharmacies will have three options regarding your patients: they can accept your prescription; refuse your prescription; or to accept it but force patients to pay and then inform them that they bear an extra financial burden because you didn’t comply with the law.

Impact On Your Patients

Whatever option you’ve taken, you have a responsibility to keep your patients informed on your position and how they will be impacted.

If you choose to opt-in, while nothing has changed, it can’t hurt to let your patient know. Proactive communication is always advised, especially if they hear of a friend or relative who’s had issues with other dentists. Hearing from you will give them piece of mind that they won’t have to worry about the coverage and care they’re receiving.

If you choose to opt-out, the same applies. Inform patients that you’ve opted out of Medicare coverage, and give them your reasons why. Be open and let them know how it will impact their care and financial responsibility. Acquaint them with private contract options and assure them that concern for their care was the primary reason for your decision.

If you don’t opt-in or opt-out, it is even more important that you inform your patients. Explain to your patients the challenges they might face in filling prescriptions and receiving coverage. Patients should not hear it for the first time from their pharmacists.

Where To Go From Here

If you are in a position where you need to take action on your current Medicare status, we’d like to refer you to some additional resources:

  • If you have not yet enrolled: Consider working with a Medicare enrollment specialist to navigate the complicated forms and application process.
  • If you are waiting on the status of your enrollment: You can view a list of enrolled providers here. This list is updated every 2 weeks.
  • If you have not yet enrolled but would like to: The forms are available here and here.
  • If you would like to opt-out: No standard form is available, but CMS does offer guidelines here.
  • If you have general questions: You may refer to the CMS interactive map to find your Medicare administrative contractor.

While the ADA has openly protested CMS’ rule, it has taken effect and ignoring it can have very real and negative implications for your practice.

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Angie Walters

Angela Walters is a Partner-in-Charge of EisnerAmper's Texas office and in the firm’s Private Client Services Group.

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