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Legal Updates

Dentists Who Write Prescriptions Must Make a Decision: Enroll in Medicare or Opt-Out


If you are a dentist who writes prescriptions to Medicare beneficiaries for drugs covered under Medicare Part D, this article contains important information for you and your patients regarding your new enrollment requirements with Medicare. Click here to read the complete legal update.
On May 23, 2014, the Centers for Medicare & Medicaid Services ("CMS") finalized CMS-4159-F "Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs" (the "New Rule"). The New Rule was authorized by section 6405(c) of the Patient Protection and Affordable Care Act.

The New Rule requires dentists1 who write prescriptions for Medicare Part D ("Part D") prescription drugs to:

  • Be enrolled in Medicare; or
  • Have a valid record on file of opting-out of Medicare for their prescriptions to be covered under Part D.

The effective date of the New Rule was June 1, 2015. However, CMS has announced that it will delay enforcement of the New Rule until December 1, 2015.
The key feature of the New Rule is the potential harm that could befall patients due to a dentist’s inaction.  Beginning December 1, 2015, Medicare will not reimburse a patient for a Part D prescription if that patient’s dentist has failed to either enroll in Medicare or expressly opt-out.
For example, a patient attempting to fill a prescription at a local pharmacy could see the pharmacist refuse to accept the prescription, or accept the prescription but force the patient to pay and tell the patient that Medicare will not reimburse the pharmacy or the patient because the patient’s dentist did not comply with the law.

CMS has also instructed that even if a dentist does not perform Medicare covered services but instead "refers out" such procedures, those colleagues or entities to which the dentist refers the Medicare covered procedures will be unable to receive reimbursement from Medicare if the referring dentist fails to enroll with Medicare or opt-out. Therefore, there is a risk that payment for Medicare covered dental services could become problematic down the line for the patient if the dentist does nothing.

As such, although it places an increased administrative burden on dentists, the New Rule’s requirement to enroll with Medicare or to opt-out will simply be a prerequisite for dentists who prescribe Part D prescription medication or refer out or perform Medicare covered dental services for eligible patients. 
Given the New Rule’s impending December 1, 2015 enforcement date, dentists who prescribe Part D medication need to take immediate action to submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors ("MACs") to ensure that the MACs have sufficient time to process the applications or opt-out affidavits. Prescribers can either visit their MAC’s website or access information on the CMS enrollment website by clicking on "Medicare Provider-Supplier Enrollment" under the "Provider Enrollment & Certification" heading.

1 The New Rule also applies to physicians and, at times, other eligible professionals.