Effective June 1, 2016, prescribers of drugs covered by Medicare Part D must either enroll in Medicare or have a valid record of opting out in order to avoid denial of their prescriptions by Part D plans. If you don’t enroll or opt-out, pharmacists will not fill your prescriptions for Part D patients. Prescribers should submit their applications to enroll or validly opt-out by Jan. 1, 2016, so that the Medicare Administrative Contractor (MAC) can process the application or affidavit in time for the June 1 enforcement date.
Prescribers can either visit their MAC’s website or access information on the Centers for Medicare & Medicaid Services (CMS) website. Providers, including dentists, who wish to enroll solely to prescribe Part D drugs and do not bill Medicare for services provided to Medicare beneficiaries can complete an abbreviated enrollment form (CMS-855O) and process.
How do I enroll in Medicare?
How do I opt-out and where can I find the opt-out form?
For more information on the opt-out process, refer to this article “Opting out of Medicare and/or Electing to Order and Refer Services to Medicare Beneficiaries.” If you wish to opt-out and prescribe drugs for Medicare beneficiaries, please be sure that your National Provider Identifier (NPI), date of birth, and Social Security Number are included in your opt-out affidavit or separately provided to the MAC, as opt-out professionals will not be allowed to prescribe if this information is missing.
What is the difference between opting out and enrolling via the CMS-8550 application?
An important distinction is that once you have opted out, the opt-out is in place for at least two years unless you change your opt-out status within 90 days after submitting your opt-out affidavit. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) changed the opt-out period renewal process so that if an opt-out affidavit is signed on or after June 16, 2015, the opt-out will be automatically renewed every two years unless the renewal is cancelled by notifying the MAC in writing at least 30 days prior to the start of the next two year opt-out period. If an opt-out affidavit was filed prior to June 16, 2015, the opt-out will expire after two years unless renewed. It is therefore important for opt-out providers to keep track of whether their opt-out status is automatically renewed or requires affirmative renewal, along with the deadline.
For more information, refer to the same article listed above.
Should I enroll in Medicare or should I opt-out?
Whether a provider enrolls in Medicare or opts-out, the provider can continue to prescribe for Medicare Part D beneficiaries. A drawback to opting out is the two year opt-out period and the need to satisfy the renewal or cancellation deadline if a change is desired.
With limited exceptions, Medicare payments cannot be made directly or indirectly for services rendered by an opt-out provider. Thus, if there is any likelihood that a provider may receive payments from Medicare or under a Medicare Advantage Plan, the provider should generally enroll in Medicare, rather than opt-out.
Who can I contact if I have questions? Where do I submit my enrollment application or opt-out affidavit?
You may refer to this interactive map to find your MAC.
Where can I get a copy of the CMS-8550/CMS-855I form? Depending on which option you choose, the forms can be found below:
- CMS-855I —Allows you to enroll to be reimbursed for the covered services furnished to Medicare beneficiaries. Reassignment of the right to bill and receive Medicare payments would also require submission of CMS-855R.
- CMS-855O —A shorter, abbreviated form, which allows you to enroll solely to prescribe, or to order and refer patients to Medicare enrolled providers and suppliers, and not to receive Medicare payment for covered services.
What if my specialty is not listed in CMS-855O?
While the CMS-8550 form states that it is for physicians and non-physician practitioners who want to order and refer, it can also be used by prescribers who want to enroll to prescribe Part D drugs. CMS has stated that it is updating the CMS-855O form to include a specialty listing for “General Dentist,” and that until then, dentists should select from either the “Maxillofacial Surgery” or “Oral Surgery (dentist only)” entries, if applicable, or select the “Undefined Physician Specialty” box and insert “General Dentist.’ CMS has likewise instructed other professionals whose specialty is not listed to select the “Undefined Physician Specialty” or “Unlisted Non-Physician Practitioner Type” box and insert the specialty.
Are prescribing pharmacists required to enroll or opt-out?
No. Medicare Part D covers prescriptions written by a pharmacist with an individual NPI if state law permits the pharmacist to write the prescription, even though pharmacists are not allowed to enroll in or opt-out of Medicare. Starting on June 1, 2016, Part D plans will be required to reject pharmacy claims by prescribing pharmacists whose taxonomy codes are not accurate in the National Plan & Provider Enumeration System (NPPES). CMS therefore recommends that pharmacists ensure that their primary taxonomy associated with their NPI in the NPPES reflects that they are pharmacists.
Are other prescribers exempt from the enrollment/opt-out requirement?
Part D covers prescriptions that are written by individuals (referred to as “other authorized prescribers”) who are authorized under state or other applicable law to write prescriptions but are not in a provider category (such as physician, nurse practitioner or physician assistant) that is permitted to enroll or opt-out of Medicare.
CMS has stated its belief that “other authorized prescribers” are largely limited to pharmacists, and has identified pharmacists as the only profession falling within this category. CMS suggests that any nonpharmacist who believes that he or she qualifies as an “other authorized prescriber” should contact CMS at firstname.lastname@example.org.
Where can I find guidance from CMS on Part D prescriber enrollment?
For more information concerning Part D prescriber enrollment, consult CMS-4159 Frequently Asked Questions (FAQs) or this article “Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs.”
How can I determine whether Medicare recognizes me as a prescriber?
CMS maintains an enrollment file that identifies physicians, dentists, and other eligible professionals who are enrolled in Medicare in an approved or opt-out status and are therefore allowed to prescribe. CMS intends to update the enrollment file every two weeks.
For more information, please contact one of the attorneys listed below.