ONLINE ONLY- Delta Dental's Latest Announcement

Centers for Medicare and Medicaid Services (CMS) previously issued a ruling whereby all healthcare providers who write prescriptions for Medicare beneficiaries must be either enrolled in Medicare or have a valid opt out affidavit on file. The implementation date for the ruling has changed several times, but the current implementation date is February 1, 2017. Insurance Solutions Newsletter has previously published various articles detailing this ruling and a practice’s options under Medicare.

A brief overview of your options under Medicare is as follows. For further detail, please refer to our previous newsletter articles or our Medicare Decision Tree resource.

Medicare Options:

1. Formally enroll in Medicare.

2. Enroll as a referring/prescribing provider only.

3. Formally opt out of Medicare.

4. Take no action.

Some dentists have elected to opt out of Medicare. Under this opt out status, reimbursement will not be provided for services performed for Medicare or Medicare Advantage Plan participants.  You must also inform your patients that you are not a Medicare provider, and that they will not receive reimbursement for the services you perform.  A patient must sign a private contract and elect to be treated as a private patient.  This means that the patient will be responsible to pay out-of-pocket for all services received.  This contract must be completed every two years by the Medicare patient.

Delta Dental Announcement

In June 2016, Delta Dental of Indiana issued an announcement in its bulletin and sent a letter to its participating providers, stating that your enrollee status in Medicare could have a direct impact on reimbursements for services provided for Medicare Advantage patients and could affect your ability to participate with Delta Dental at all. These new contract provisions are set to become effective at the beginning of 2017.  Delta Dental of Michigan has also issued a similar statement to their providers.

Providers who opt out of Medicare following this announcement, you will no longer be allowed to participate in any of Delta Dental’s networks, including Delta Premier and Delta PPO. Providers who opted out before the announcement will be able to participate through the current opt out term.  It is indicated that, during this “grandfathered phase,” opted out providers will be allowed to submit claims to Delta for all networks with which they participate.  However, they will not receive reimbursement for services provided to patients enrolled in a Medicare Advantage Plan.  Furthermore, any grandfathered providers must comply with this new contract provision after the current two year opt out period ends. 

Impact of the Announcement

If your practice’s providers are grandfathered during a current, active two year opt out period and would like to continue participation with Delta Dental, they will need to change their Medicare enrollment status at the end of the current two year opt out period. This could be problematic for some providers, because all opt-out affidavits signed on or after June 15, 2015 will automatically renew.  Therefore, any provider who wants to continue participation in the Delta Dental network should be aware that he or she will need to notify Medicare, in writing, of the intent to terminate the existing opt out agreement at least 30 days prior to the end of the current opt out period.  At that time, the provider must elect to enroll in Medicare as either an ordering/referring provider or as a service provider under Medicare Part B. 

(Note: Providers may elect to enroll in Medicare however they prefer.  They can also still choose to opt-out, but should understand that this Medicare status will affect their relationship with Delta Dental in some states, resulting in the provider being dropped from Delta Dental Premier and PPO networks.) 

Participation in Medicare and Medicare Advantage Plans goes beyond simply enrolling. Medicare requires that all providers complete Fraud, Waste, and Abuse (FWA) training.  This training must be completed during the 2017 calendar year, and must be done each year thereafter.  Training is available online, and is simple to complete.  However, it is important that this training be completed in order to comply with your enrollment provisions.  For more information, please visit CMS’s website www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-Products.pdf.

All training programs are approved by CMS, but many are payer specific. When this is the case, the payer will typically provide a link through its own website for the required Fraud, Waste, and Abuse training.  After training is finished, a form is usually provided confirming that the provider completed training.

Another requirement of this new contract provision is that Delta Dental providers will now be required to present Medicare patients with an “ Advanced Beneficiary Notice” (ABN). This notice states that the patient understands that the services provided will not be covered by their insurance plan, the patient will be required to pay for those services out-of-pocket, and no claims will be filed be either the provider or the patient for those services.  Obtaining a signed ABN is something that has not been required of dental providers in the past.  Many practices are probably not aware of this Medicare requirement, nor are they familiar with the form required.  For more information, please visit CMS’s website www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf.

Final Thoughts

The fact that opting out of Medicare can affect participation with or reimbursement from certain plans has been known for a while now. Also, this is not something that is exclusive to Delta Dental.  For example, Aetna has notified participating providers that FWA training is required per the Aetna PPO Provider Contract.  Aetna is the administrator of government sponsored plans, such as Medicare Advantage Plans, and is therefore requiring all contracted providers to complete this training.

At this time, it appears that only Delta Dental of Indiana and Michigan have notified providers of these new Medicare contract provisions. CMS has stated that no Medicare funds may be issued to providers who have opted out of Medicare, including services that are covered under Medicare Advantage Plans.  This includes those Delta Dental Plans that administer dental benefits for Medicare Advantage Plans.  Check with your state’s Delta Dental Plan to determine your specific requirements.  It is expected that, in the future, all Delta Plans will feature these Medicare participation requirements.

It is important to note that provider contracts can sometimes be ambiguous and may create confusion for the practice. Whenever you have questions regarding your provider contract, contact the payer’s provider relations department for clarification, or refer to a healthcare attorney familiar with such matters.