Medicare opt in, opt out: What does it all mean…for now?

July 23, 2018|Kendall Butler

Medicare rules surrounding dentist enrollment have changed. Learn how you may be affected and what options you have.

It is very challenging to keep up with Medicare rule changes, and often more problematic to understand them! This article summarizes the Medicare rules that changed in May 2018 and confirmed by the Wisconsin Dental Association (WDA).

On May 1, 2018, the American Dental Association (ADA) made an announcement with regard to Medicare and dentists, noting that the Centers for Medicare and Medicaid Services (CMS) published their final rule revising Part C (Medicare Advantage Plans) and Part D (Prescription Drug Benefit). The newly passed rule removes the requirement that dentists must either “opt in or opt out” of Medicare for beneficiaries to receive prescription or supplemental plan benefits. After June 15, 2018 when this final rule went into effect, dentists no longer need to opt out or enroll for patients to receive either of these benefits. This is a big win for dentists!

Exception to the new Medicare rules

However, this rule does not apply to dentists who order clinical laboratory services (such as sending specimens for pathology services) and imaging center services for Medicare beneficiaries; dentists will still need to either enroll or opt out for those agencies to receive payment. The ADA put forth the new rule to address this issue as well, but CMS did not comply with this request. If a dentist uses lab or imaging services, then that referring dentist must be registered within the Medicare system.

Registering as an ordering/referring provider does not make you a full Medicaid provider where you will need to accept a lower fee schedule. This only allows those agencies to which you refer to be paid. No harm done to enroll with this status going forward and it will cover any possible referrals you make.

What does this mean for 98% of all general dentists?

It means that while you are no longer required by law to do anything, it does not mean that you shouldn’t!

To simplify this overcomplicated ruling, think about it this way. You have three choices:

  1. Enroll in Medicare as a full provider
  2. Do nothing (or having opted out of Medicare after June 16, 2015)
  3. Enroll as an ordering and referring provider (if you refer beneficiaries for lab or imaging services)

Once approved, the term is still active for two years, meaning that you will need to redo the documentation every two years to maintain the ordering/referring provider status.

If you opted out of Medicare completely after June 15, 2015, this status will be automatically renewed every two years with no effort on the part of the dentist. Should you wish to change that status, you must notify Medicare in writing 30 days prior to the new two-year renewal period.

To be clear, if you opted out completely and you wish to change your status to one of ordering/referring, you must notify Medicare in writing 30 days prior to renewal, fill out the documentation (CMS 855O form) and resubmit all as an ordering/referring provider.

The American Dental Association created a webpage dedicated to Medicare, including facts and frequently asked questions. Please note that doctors must use their ADA log in credentials to view the full content.

For assistance understanding Medicare regulations, contact Kendall Butler or any member of the Dental Advisory Group at Schenck at 800-236-2246.


Kendall Butler is a dental practice efficiency specialist with more than 25 years of experience in health care. She works with doctors, practice managers, hygiene teams and support staff to identify ways to enhance practice efficiency and profitability.

Erika Valadez is a dental practice & government relations associate with the Wisconsin Dental Association’s legislative office in Madison.