In a 2016 final rule on the Physician Fee Schedule (PFS), the Centers for Medicare and Medicaid Services (CMS) included a new requirement for dentists in Medicare Advantage plan networks (“Part C” plans) to be enrolled in Medicare in an “approved status.” Approved status means:

  • For the “Part C” rule (Medicare Advantage plans), use of the CMS-855I (long form) to enroll (this form was cited in the CMS rule as appropriate for enrollment).
  • For the “Part D” rule (prescriptions), use of the CMS-855I (long form) or the CMS-855O (short form) to enroll (with approval of those applications by the Medicare Administrative Contractor in the state).

Please review the notice developed by the National Association of Dental Plans and the American Dental Association. It addresses the Centers for Medicare and Medicaid Services requirements about enrolling in Medicare and how you may be affected.

In general, apart from a very limited exception for emergency care, the PFS rule will require dentists who submit claims to a Medicare Advantage plan for any covered dental service to be enrolled in an approved status before January 1, 2019.

The PFS rule is like the Part D rule for Medicare reimbursement for prescription drugs issued earlier by CMS. The Part D rule also requires dentists to be enrolled in an approved status for their patients to be eligible for Medicare reimbursement for drugs prescribed by the dentist and has the same compliance date of January 1, 2019.

While opting out of Medicare is a valid option for dentists to satisfy the Part D rule, opting out is not an option under the Part C rule.

Also, opting out in response to the Part D rule, or not filing an application in response to the Part C rule, will prevent Medicare Advantage plans (including Delta Dental) from paying dentists for dental services provided under a Medicare Advantage plan, effective January 1, 2019.