The number of participating doctors in Medicare is remarkably low. That is understandable, since “Medicare doesn’t cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices.” source
However, Medicare will begin offering supplemental dental insurance to Medicare participants through 3rd party insurance companies. These are known as Medicare Advantage Plans. In other words, Medicare is offering private dental insurance through private dental insurance companies. Here’s the catch… The federal government gets to set the fee schedule. So if you want to participate in the the medicare advantage plans, through any given provider, you have to be willing to take the federal fee schedule.
So before you sign up for the Medicare Advantage Plans, you need to review the fee schedule, as you would any other dental PPO fee schedule, and decide if it makes business sense to work at the discounted fee schedule. If you are in Arizona, the easiest way to describe these plans would be “AHCCCS for Medicare Patients”. The fee schedule would be the same as the AHCCCS fee schedule.
A quick example of some commonly billed codes on the AHCCCS fee schedule.
- D0150 Comprehensive Exam – $38.33
- D0210 Full Mouth Series – $66.02
- D1110 Adult Prophy – $46.71
- D2392 2-Surface Posterior Resin – $82.10
- D2792 Noble Crown – $514.70
- D3330 Molar RCT – $507.48
For a full fee schedule, click here.
The ADA Benefit Plan Analyzer may be a useful tool in helping you decide what impact Medicare participation, as well as any other PPO, will have on your practice. click here.
So if you decide to participate in the Medicare Advantage Plans, you will be agreeing to this fee schedule like any other PPO that you would sign up for. There may be some benefits with some of these plans. Since these plans are administered by a 3rd party, they may have less paperwork than you would expect from a government program, less pre-authorization needed and may have higher benefit levels than the typical $1000-$1500 benefit level of most dental benefit plans.
However, EVEN if you decide NOT to participate in Medicare Advantage plans, you can still be affected by the new laws. Here’s how…
If you order or refer covered clinical laboratory services (biopsies), imaging services, or DMEPOS (apnea devices) for Medicare patients you will need to either enroll in Medicare or formally “opt out” of Medicare. For more information, click here.
As of Dec. 1, 2015, Medicare will require all physicians, including dentists, who prescribe Part D covered drugs to their patients to either be enrolled in Medicare OR must “opt out” of Medicare, in order for their patient’s prescriptions to be covered by Part D.
Doctors who “opt out” of Medicare are required to have written contracts with the Medicare beneficiary stating that the doctor and the patient have forfeited the right to bill Medicare, and the patient is essentially paying a “fee for service” out of their own pocket. The doctor must also submit an affidavit to Medicare expressing their desire to “opt out” of the Medicare program. This “opt out” affidavit is for a period of 2 years. So while all dentists are free to participate in Medicare, there are new compliance issues if you choose not to participate.