Medicare Opt In/Out Update

The Center for Medicare and Medicaid Services (CMS) recently announced that the effective date for changes to the Medicare Prescription Drug program has been delayed until January 1, 2019. As of January 1, 2019, in order to have prescriptions they have written covered under Medicare Part D, eligible providers must either 1) be enrolled in Medicare under an approved status or 2) have a valid opt out affidavit on file. 

Dentists are strongly encouraged to submit an opt-out affidavit or enrollment form as soon as possible.

If a provider chooses to take no action, starting January 1, 2019, any prescriptions they write for patients that are covered under Medicare Part D will be denied. 

A dentist can opt into Medicare one of two ways:
1. Complete form CMS 855i which will enroll the dentist into Medicare for ALL eligible Medicare Services or
2. Complete form CMS 855o which will allow eligible prescriptions for Medicare patients to be processed. 

Forms may be obtained by using the following:
Medicare generally does not cover routine dental services; however a narrow exception permits coverage of certain dental services that are necessary to the provision of certain Medicare covered medical services. Medicare may also cover certain medical procedures that dentists are licensed to perform, such as biopsies for oral cancer.  For more information on the services Medicare covers, please see CMS’s website, “Medicare Dental Coverage.” 

Dentists can opt out of Medicare by completing an affidavit, which must be updated every two years,  and sending it to the Medicare carrier. By opting out of Medicare, eligible prescriptions written for Medicare patients will be processed. HOWEVER, providers will not be eligible to receive any reimbursements from Medicare for a two year period. Dentists who are considering opting out should also understand that by opting out, dentists will be precluded from participating in Medicare Advantage programs, which offer Medicare benefits through private insurance, and offer benefits not covered by traditional Medicare.

Dentists should notify Novitas Solutions, Inc., the Medicare carrier for Pennsylvania, of their decision to opt in or opt out as soon as possible, in order to allow time to process enrollments.  
The appropriate form should be sent to:

Novitas Solutions, Inc
Provider Enrollment Services
PO Box 3157
Mechanicsburg, PA 17055-1836

More information about Medicare opt in/opt out, and which decision may be best for your practice, can be found on ADA’s Center for Professional Success’s website at

For questions concerning Medicare opt in/opt out, please contact the PDA Central Office at (800) 223-0016, and ask to speak with the Government Relations Department.