New Medicare opt in/opt out requirement for prescribers of drugs covered by Medicare Part D (now including dentists)

April 10, 2015

Alert

Effective Dec. 1, 2015, persons who prescribe drugs covered by Medicare Part D to their patients must either enroll in Medicare or have a valid record of opting out. Among others, dentists are now subject to this requirement. If you neither enroll nor opt out, pharmacists will not fill your prescriptions for patients covered by Medicare Part D. Prescribers should submit their application to enroll or validly opt out by June 1, 2015, so that the Medicare contractors can process the applications or affidavits in time for the Dec. 1, 2015, enforcement date.

Prescribers can either visit their Medicare Administrative Contractor’s (MACs) website or access information on the Centers for Medicare & Medicaid Services (CMS) by going to CMS.gov and clicking on “Medicare Provider—Supplier Enrollment” under the “Provider & Certification” heading. Providers, including dentists, who wish to enroll solely to prescribe Part D drugs and who do not bill Medicare for services provided to Medicare beneficiaries can complete an abbreviated enrollment form and process that the MACs can explain.

How do I enroll in Medicare?

Providers can enroll in Medicare by using either Internet-based PECOs or by completing the paper 8551 or 8550 application, which can be downloaded at CMS.gov.

How do I opt out and where can I find the opt out form?

For more information on the opt out process, refer to MLN Matters^® article SE1311, titled “Opting out of Medicare and/or Electing to Order and Refer Services,” which is available on the CMS website. If you wish to opt out and prescribe drugs for Medicare beneficiaries please be sure that your 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?

For more information, refer to MLN Matters^® article SE1311, titled “Opting out of Medicare and/or Electing to Order and Refer Services,” which is available on the CMS website. Please note that once you have opted out, that opt out is in place for two years. You are also required to update the opt out affidavit every two years. CMS does not notify opt out providers of the need to renew the opt out affidavit every two years.

Who can I contact if I have questions?

You may refer to the interactive map to find your MAC.

Where do I submit my enrollment application or opt out affidavit?

You may refer to the 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.

CMS-8550—A shorter, abbreviated form, which allows you to enroll solely to order and/certify and/or prescribe Part D drugs. While the CMS-8550 form states it is for physicians and non-physician practitioners who want to order and refer, it is appropriate for use by prescribers who also want to enroll to prescribe Part D drugs. Our understanding is that the form CMS-8550 is being updated to include a General Dentistry listing in addition to those for Maxiofacial Surgery and Oral Surgery.

Should I enroll in Medicare or should I opt out?

Regardless of whether a provider enrolls in Medicare or opts out, the provider can continue to prescribe for Medicare Part D beneficiaries. The drawback to opting out is that it would be effective for two years. A prescriber who has opted out would need to renew that opt out status every two years in order to continue prescribing to Medicare Part D beneficiaries.

With limited exceptions, Medicare payments cannot be made directly or indirectly for services rendered by an opt out provider. Therefore, no payment will be made under Medicare or under a Medicare Advantage Plan 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 enroll in Medicare.

For detailed information concerning this matter, consult CMS-4159 Frequently Asked Questions (FAQs).

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.

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