HR4146-118

1. Short title This Act may be cited as the Medicare Dental Benefit Act of 2023.

2. Coverage of dental services under the Medicare program Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— in subparagraph (II), by striking and at the end; in subparagraph (JJ), by adding and at the end; and by adding at the end the following new subparagraph: dental and oral health services (as defined in subsection (nnn)); Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection: The term dental and oral health services means services (as defined by the Secretary) that are necessary to prevent disease and promote oral health, restore oral structures to health and function, reduce oral pain, and treat emergency conditions, including— routine diagnostic and preventive care such as dental cleanings, exams, and x-rays; basic dental services such as fillings and extractions; major dental services such as root canals, crowns, and dentures; emergency dental care; and other necessary services related to dental and oral health (as defined by the Secretary). Section 1861(ddd)(3) of the Social Security Act (42 U.S.C. 1395x(ddd)(3)) is amended by adding at the end the following new subparagraph: Dental and oral health services described in paragraph (1) of subsection (nnn), relating to routine diagnostic and preventive care. Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended— by striking “and” before “(HH)”; and by inserting before the semicolon at the end the following: “and (II) with respect to dental and oral health services (as defined in section 1861(nnn), other than those services described in paragraph (1) of such section), the amount paid shall be the payment amount specified under section 1834(aa).”. Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection: The payment amount under this part for dental and oral health services (as defined in section 1861(nnn), other than those services described in paragraph (1) of such section) shall be, subject to paragraph (3), the applicable percentage (specified in paragraph (2)) of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848. For purposes of paragraph (1), subject to subparagraph (B), the applicable percentage specified in this paragraph is— for the first year beginning at least 6 months after the date of the enactment of this subsection, 0 percent; for the year following the year specified in subparagraph (A) and each subsequent year through the seventh year following the year specified in subparagraph (A), the applicable percent specified in this paragraph for the previous year increased by 10 percentage points; and for the eighth year following the year specified in subparagraph (A) and each subsequent year, 80 percent. For purposes of paragraph (1), with respect to dental and oral health services described in such paragraph that are furnished to an individual who is a subsidy eligible individual (as defined in section 1860D–14(a)(3)), or who would be a subsidy eligible individual if the individual were enrolled in a prescription drug plan or an MA–PD plan under part D, for the first year beginning at least 6 months after the date of the enactment of this subsection and each subsequent year, the applicable percent specified in this paragraph is 80 percent. With respect to dental and oral health services that are— routine dental cleanings, payment may be made under this part for only two such cleanings during a 12-month period; and routine exams, payment may be made under this part for only two such exams during a 12-month period. The Secretary may apply such other reasonable limitations on the extent to which dental and oral services are covered under this part, including through application of a prior authorization requirement. Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of dental and oral health services to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force. The Secretary may waive any frequency limitation or other limitation as described in this paragraph for an individual (or category of individuals) as determined appropriate by the Secretary. Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by striking risk assessment) , and inserting risk assessment), (2)(KK),. Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)) is amended— by striking (other than dental) and inserting (including dental); and by striking internal body. Section 1834(a) of the Social Security Act (42 U.S.C. 1395m(a)) is amended by adding at the end the following new paragraph: The payment amount under this part for dental prostheses shall be, subject to subparagraph (C), the applicable percent (specified in subparagraph (B)) of the amount otherwise payable for such dental prostheses under this section. For purposes of subparagraph (A), subject to clause (ii), the applicable percent specified in this subparagraph is— for the first year beginning at least 6 months after the date of the enactment of this paragraph, 0 percent; for the year following the year specified in clause (i) and each subsequent year through the seventh year following the year specified in clause (i), the applicable percent specified in this subparagraph for the previous year increased by 10 percentage points; and for the eighth year following the year specified in clause (i) and each subsequent year, 80 percent. For purposes of subparagraph (A), with respect to dental prostheses furnished to an individual who is a subsidy eligible individual (as defined in section 1860D–14(a)(3)), or who would be a subsidy eligible individual if the individual were enrolled in a prescription drug plan or an MA–PD plan under part D, for the first year beginning at least 6 months after the date of the enactment of this paragraph and each subsequent year, the applicable percent specified in this subparagraph is 80 percent. Payment may be made under this part for an individual for— not more than one full upper and one full lower dental prostheses once every five years; and not more than one partial upper dental prostheses and one partial lower dental prostheses once every five years. The Secretary may apply such other reasonable limitations on the extent to which dental prostheses are covered under this part, including through application of a prior authorization requirement. Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of dental prostheses to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force. The Secretary may waive any frequency limitation or other limitation as described in this subparagraph for an individual (or category of individuals) as determined appropriate by the Secretary Section 1862(a) of the Social Security Act (42 U.S.C. 1395y) is amended by striking paragraph (12). The amendments made by this section shall apply to services furnished on or after January 1, 2025. (KK)dental and oral health services (as defined in subsection (nnn));. (nnn)Dental and oral Health ServicesThe term dental and oral health services means services (as defined by the Secretary) that are necessary to prevent disease and promote oral health, restore oral structures to health and function, reduce oral pain, and treat emergency conditions, including— (1)routine diagnostic and preventive care such as dental cleanings, exams, and x-rays; (2)basic dental services such as fillings and extractions; (3)major dental services such as root canals, crowns, and dentures; (4)emergency dental care; and (5)other necessary services related to dental and oral health (as defined by the Secretary).. (D)Dental and oral health services described in paragraph (1) of subsection (nnn), relating to routine diagnostic and preventive care.. (aa)Payment and limits for dental and oral health services (1)In generalThe payment amount under this part for dental and oral health services (as defined in section 1861(nnn), other than those services described in paragraph (1) of such section) shall be, subject to paragraph (3), the applicable percentage (specified in paragraph (2)) of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848. (2)Applicable percentage (A)In generalFor purposes of paragraph (1), subject to subparagraph (B), the applicable percentage specified in this paragraph is— (i)for the first year beginning at least 6 months after the date of the enactment of this subsection, 0 percent; (ii)for the year following the year specified in subparagraph (A) and each subsequent year through the seventh year following the year specified in subparagraph (A), the applicable percent specified in this paragraph for the previous year increased by 10 percentage points; and (iii)for the eighth year following the year specified in subparagraph (A) and each subsequent year, 80 percent. (B)Special rule for certain low-income individualsFor purposes of paragraph (1), with respect to dental and oral health services described in such paragraph that are furnished to an individual who is a subsidy eligible individual (as defined in section 1860D–14(a)(3)), or who would be a subsidy eligible individual if the individual were enrolled in a prescription drug plan or an MA–PD plan under part D, for the first year beginning at least 6 months after the date of the enactment of this subsection and each subsequent year, the applicable percent specified in this paragraph is 80 percent. (3)Limitations and Secretarial authority (A)FrequencyWith respect to dental and oral health services that are— (i)routine dental cleanings, payment may be made under this part for only two such cleanings during a 12-month period; and (ii)routine exams, payment may be made under this part for only two such exams during a 12-month period. (B)Secretarial authority (i)Authority to apply additional limitationsThe Secretary may apply such other reasonable limitations on the extent to which dental and oral services are covered under this part, including through application of a prior authorization requirement. (ii)Authority to modify coverageNotwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of dental and oral health services to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force. (iii)Authority to waive frequency limitationsThe Secretary may waive any frequency limitation or other limitation as described in this paragraph for an individual (or category of individuals) as determined appropriate by the Secretary.. (23)Payment and limits for dental prostheses (A)In generalThe payment amount under this part for dental prostheses shall be, subject to subparagraph (C), the applicable percent (specified in subparagraph (B)) of the amount otherwise payable for such dental prostheses under this section. (B)Applicable percent (i)In generalFor purposes of subparagraph (A), subject to clause (ii), the applicable percent specified in this subparagraph is— (I)for the first year beginning at least 6 months after the date of the enactment of this paragraph, 0 percent; (II)for the year following the year specified in clause (i) and each subsequent year through the seventh year following the year specified in clause (i), the applicable percent specified in this subparagraph for the previous year increased by 10 percentage points; and (III)for the eighth year following the year specified in clause (i) and each subsequent year, 80 percent. (ii)Special rule for certain low-income individualsFor purposes of subparagraph (A), with respect to dental prostheses furnished to an individual who is a subsidy eligible individual (as defined in section 1860D–14(a)(3)), or who would be a subsidy eligible individual if the individual were enrolled in a prescription drug plan or an MA–PD plan under part D, for the first year beginning at least 6 months after the date of the enactment of this paragraph and each subsequent year, the applicable percent specified in this subparagraph is 80 percent. (C)Limitations and Secretarial authority (i)In generalPayment may be made under this part for an individual for— (I)not more than one full upper and one full lower dental prostheses once every five years; and (II)not more than one partial upper dental prostheses and one partial lower dental prostheses once every five years. (ii)Secretarial authority (I)Authority to apply additional limitationsThe Secretary may apply such other reasonable limitations on the extent to which dental prostheses are covered under this part, including through application of a prior authorization requirement. (II)Authority to modify coverageNotwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of dental prostheses to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force. (III)Authority to waive frequency limitationsThe Secretary may waive any frequency limitation or other limitation as described in this subparagraph for an individual (or category of individuals) as determined appropriate by the Secretary.

3. Increased FMAP for additional expenditures for medicare cost-sharing for dental and oral health services Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended— in subsection (b), by striking and (ii) and inserting (ii), and (jj); and by adding at the end the following new subsection: Notwithstanding subsection (b), with respect to the portion of the amounts expended by a State for medical assistance for medicare cost-sharing (as defined in subsection (p)(3)) for qualified medicare beneficiaries described in subsection (p)(1) that is attributable to the coverage under part B of title XVIII of dental and oral health services (as defined in section 1861(nnn)), as determined by the Secretary, the Federal medical assistance percentage for a State that is one of the 50 States or the District of Columbia shall be equal to 100 percent. (jj)Increased FMAP for additional expenditures for medicare cost-Sharing for dental and oral health servicesNotwithstanding subsection (b), with respect to the portion of the amounts expended by a State for medical assistance for medicare cost-sharing (as defined in subsection (p)(3)) for qualified medicare beneficiaries described in subsection (p)(1) that is attributable to the coverage under part B of title XVIII of dental and oral health services (as defined in section 1861(nnn)), as determined by the Secretary, the Federal medical assistance percentage for a State that is one of the 50 States or the District of Columbia shall be equal to 100 percent..

4. Preventive Services Taskforce Section 915(a)(1) of the Public Health Service Act (42 U.S.C. 299b–4(a)(1)) is amended, in the first sentence, by inserting , including at least 1 oral health professional after expertise. The amendment made by subsection (a) shall take effect January 1, 2025.