[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4624 Introduced in House (IH)]







109th CONGRESS
  1st Session
                                H. R. 4624

  To amend title XIX of the Social Security Act to require States to 
 provide oral health services to children and aged, blind, or disabled 
    individuals under the Medicaid Program, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           December 17, 2005

  Mr. Boustany (for himself and Mr. Andrews) introduced the following 
    bill; which was referred to the Committee on Energy and Commerce

_______________________________________________________________________

                                 A BILL


 
  To amend title XIX of the Social Security Act to require States to 
 provide oral health services to children and aged, blind, or disabled 
    individuals under the Medicaid Program, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Special Care Dentistry Act of 
2005''.

SEC. 2. REQUIREMENT TO PROVIDE CHILDREN AND AGED, BLIND, OR DISABLED 
              INDIVIDUALS WITH ORAL HEALTH SERVICES UNDER THE MEDICAID 
              PROGRAM.

    (a) In General.--Title XIX of the Social Security Act (42 U.S.C. 
1396 et seq.) is amended--
            (1) by redesignating section 1936 as section 1937; and
            (2) by inserting after section 1935, the following:

   ``oral health services for children and aged, blind, or disabled 
                              individuals

    ``Sec. 1936. (a) Expansion of EPSDT.--
            ``(1) In general.--A State plan under this title shall 
        provide, subject to the succeeding provisions of this section 
        and through a plan amendment, for the provision of oral health 
        services for children who are eligible for medical assistance 
        under the State program under this title and aged, blind, or 
        disabled individuals described in subsection (b) as part of the 
        early and periodic screening, diagnostic, and treatment 
        services described in section 1905(r) (in this section referred 
        to as `EPSDT services') that are provided under the State plan.
            ``(2) Application of epsdt requirements.--The requirements 
        applicable under this title and the State plan with respect to 
        the provision of EPSDT services that are oral health services, 
        including payment structures, access requirements, 
        participation goals, and standards of care, shall apply to the 
        provision of oral health services for aged, blind, or disabled 
        individuals described in subsection (b) in the same manner as 
        such requirements apply to the provision of such services to 
        children.
            ``(3) Special care waiver to provide services under a 
        separate state adult dental program.--The Secretary may permit 
        a State to provide oral health services for aged, blind, or 
        disabled individuals described in subsection (b) through a 
        separate State adult dental program if the State demonstrates 
        that the services and fees provided and program requirements 
        under the waiver are at least equivalent to the services, fees, 
        and requirements that are provided to children under this title 
        and include age-appropriate services for such individuals.
            ``(4) Medical necessity.--EPSDT services that are oral 
        health services (other than purely cosmetic dental or oral 
        health procedures, as defined by the Secretary) provided to 
        children who are eligible for medical assistance under the 
        State program under this title or to aged, blind, or disabled 
        individuals described in subsection (b) are deemed to be 
        medically necessary. A State or any organization with an 
        agreement with the State to provide oral health services to 
        such children or individuals, may not require a physician's 
        authorization (by signature or otherwise) before oral health 
        services may be provided to such children or individuals or 
        reimbursement for the provision of such services to such 
        children or individuals may be made.
            ``(5) Prohibition on funding limitation.--Notwithstanding 
        any other provision of law, no Federal or State agency shall 
        establish any policy that is designed to limit the federal 
        dollars expended for EPSDT services that are oral health 
        services for children who are eligible for medical assistance 
        under the State program under this title or for aged, blind, or 
        disabled individuals described in subsection (b).
    ``(b) Aged, Blind, or Disabled Individuals Described.--For purposes 
of subsection (a), an aged, blind, or disabled individual described in 
this subsection is an individual--
            ``(1) who is eligible for medical assistance under 
        subclause (I) or (II) of section 1902(a)(10)(A)(i) (but only, 
        in the case of subclause (I), with respect to an individual who 
        is so eligible on the basis of receiving aid or assistance 
        under any plan of the State approved under title I, X, XIV, or 
        XVI); or
            ``(2) who would be considered an aged, blind, or disabled 
        individual under section 1614 (without regard to whether the 
        individual satisfies the income and resource requirements for 
        receiving supplemental security income benefits under title 
        XVI) and is otherwise eligible for medical assistance under the 
        State plan or under a waiver of such plan.
    ``(c) Applicable FMAP.--With respect to oral health services 
furnished in a State for calendar quarters in a calendar year to 
children eligible for medical assistance under the State program under 
this title or to aged, blind, or disabled individuals described in 
subsection (b), the Federal medical assistance percentage shall be 
equal to 90 percent.
    ``(d) Requirements for Payments.--
            ``(1) No cost-sharing or caps on services.--Notwithstanding 
        any other provision of this title, no cost-sharing and no 
        annual maximum amount of payment for, or level of, services 
        shall be imposed with respect to the provision of--
                    ``(A) EPSDT services that are oral health services 
                provided to children who are eligible for medical 
                assistance under the State program under this title; 
                and
                    ``(B) oral health services to aged, blind, or 
                disabled individuals described in subsection (b).
            ``(2) Payment rates and covered procedures.--
                    ``(A) Minimum period of applicability.--With 
                respect to each 12-month period that begins on the date 
                a State establishes or increases the payment rates or 
                types of procedures to which such rates apply with 
                respect to oral health services for children who are 
                eligible for medical assistance under the State program 
                under this title or aged, blind, or disabled 
                individuals described in subsection (b), the State may 
                not decrease such rates or types of procedures before 
                the end of the succeeding 12-month period.
                    ``(B) Notice of reduction required.--
                Notwithstanding subparagraph (A), a State may not 
                decrease the payment rates or the types of procedures 
                to which such rates apply with respect to oral health 
                services for children who are eligible for medical 
                assistance under the State program under this title or 
                aged, blind, or disabled individuals described in 
                subsection (b) without providing notice of the proposed 
                decrease to providers of such services and provider 
                organizations in the State during the preceding 12-
                month period.
                    ``(C) Criteria.--In establishing payment rates and 
                the types of procedures to which such rates apply with 
                respect to oral health services for children who are 
                eligible for medical assistance under the State program 
                under this title or aged, blind, or disabled 
                individuals described in subsection (b), a State shall 
                include appropriate and necessary procedures for such 
                children and individuals, and shall establish payment 
                rates that promote access to such services at a level 
                equal to that of the general population.
                    ``(D) Use of oral health minimum data set.--In 
                establishing payment rates for nursing facilities and 
                skilled nursing facilities under title XVIII, the State 
                shall rely on guidance from the Secretary to include 
                the oral health section of the Minimum Data Set 
                (commonly referred to as `MDS') to establish payment 
                rates for such facilities.
            ``(3) Provider code selection.--A provider of oral health 
        services for children who are eligible for medical assistance 
        under the State program under this title or aged, blind, or 
        disabled individuals described in subsection (b) shall be 
        allowed to bill for the provision of such services, regardless 
        of whether the services are to be paid under this title or 
        title XVIII, using codes established or recognized by the 
        American Dental Association.
    ``(e) Post-Eligibility Treatment of Income (PETI) Provisions.--
            ``(1) Allowance of multiple month deductions.--A State 
        shall allow a resident of a nursing facility or of a skilled 
        nursing facility under title XVIII who is an aged, blind, or 
        disabled individual described in subsection (b) and who 
        receives oral health services multiple month deductions with 
        respect to the provision of such services on a particular date. 
        Except for a resident's personal monthly allowance, fees 
        reimbursed through post-eligibility treatment of income 
        procedures under the State program under this title shall be 
        paid using the full amount of such a resident's applied income 
        each month (shared proportionally between providers if multiple 
        bills exist) until the outstanding balance of any bill for such 
        services is paid in full or otherwise eliminated.
            ``(2) Notice of amount of available income.--Upon receipt 
        of a signed release from a resident of a nursing facility or 
        skilled nursing facility under title XVIII who is an aged, 
        blind, or disabled individual described in subsection (b) who 
        has requested oral health services, or such resident's 
        representative, the State shall furnish a provider of oral 
        health services with the amount of applied income available for 
        that resident not later than 5 days after receipt of the 
        release.
            ``(3) Compliance with applied income laws.--Each State 
        shall comply with Federal requirements relating to applied 
        income adjustments for residents of nursing facilities and 
        skilled nursing facilities under title XVIII and shall provide 
        the Secretary with procedural information documenting how fee 
        reimbursements are made through applied income adjustments for 
        such residents who reside in such facilities in the State.
            ``(4) Notification of fee reimbursement mechanism.--The 
        State annually shall notify nursing facilities, skilled nursing 
        facilities under title XVIII, providers of oral health 
        services, and other appropriate agencies or organizations of 
        the ability to provide fee reimbursements for oral health 
        services through applied income adjustments for facility 
        residents and of the procedural requirements related to such 
        reimbursements.
            ``(5) Notice of availability of services.--The State shall 
        notify residents of nursing facilities or skilled nursing 
        facilities under title XVIII (or representatives of such 
        residents) of--
                    ``(A) the availability of oral health services; and
                    ``(B) in the case of each such resident who is an 
                aged, blind, or disabled individual described in 
                subsection (b), the amount of applied income available 
                each month to such resident to purchase such services 
                concurrent with the first determination of the applied 
                income of such resident.
            ``(6) Direct payment to providers.--If the State has a 
        signed assignment of benefits from a resident of a nursing 
        facility or a skilled nursing facility under title XVIII who is 
        an aged, blind, or disabled individual described in subsection 
        (b) or a legal representative of such a resident, the State 
        shall pay a provider of oral health services directly for such 
        services from the resident's applied income adjustments not 
        later than 25 days after the date on which the State received 
        the assignment.
            ``(7) Assurance of treatment of income.--If the State pays 
        a nursing facility or a skilled nursing facility under title 
        XVIII on a prospective basis for oral health services, the 
        State shall assure--
                    ``(A) that Pre-Eligiblity Treatment of Income 
                matches all rules and regulations that apply to Post-
                Eligibility Treatment of Income; and
                    ``(B) access through applied income.
            ``(8) Prohibition on limitations on fees for certain 
        services.--A State may not set a fee limit or a fee schedule 
        for oral health services purchased by residents of a nursing 
        facility or a skilled nursing facility under title XVIII who is 
        an aged, blind, or disabled individual described in subsection 
        (b) or a legal representative of such a resident through 
        applied income provisions.
            ``(9) Provider reimbursement selection.--
                    ``(A) In general.--A State shall permit a provider 
                of oral health services to children who are eligible 
                for medical assistance under the State program under 
                this title or aged, blind, or disabled individuals 
                described in subsection (b) to choose on a patient-by-
                patient basis and on a provider-by-provider basis, when 
                to seek reimbursement for the provision of such 
                services under this title or title XVIII, a program 
                operated under a waiver described in subsection (a)(3), 
                or through post-eligibility treatment of income 
                procedures in accordance with the provisions of 
                paragraph (1).
                    ``(B) Requirements.--A State shall ensure that the 
                procedures established for provider reimbursement 
                selection in accordance with this paragraph--
                            ``(i) comply with the requirements of 
                        subsection (a)(4) (prohibiting any prior 
                        authorization requirement for the provision of, 
                        or reimbursement for, oral health services); 
                        and
                            ``(ii) do not permit a provider to obtain 
                        reimbursement for the same procedure under more 
                        than 1 of the reimbursement options described 
                        in subparagraph (A).
    ``(f) Transportation.--The State shall provide transportation for 
children eligible for medical assistance under the State program under 
this title and aged, blind, or disabled individuals described in 
subsection (b) to dental offices, hospitals, clinics, or other 
treatment centers for the provision of oral health services to the same 
extent that transportation is provided under the State plan for other 
medical assistance.''.
    (b) Definition of Oral Health Services.--
            (1) In general.--Section 1905 of the Social Security Act 
        (42 U.S.C. 1396d) is amended--
                    (A) in subsection (a), by striking paragraph (10) 
                and inserting the following:
            ``(10) oral health services (as defined in subsection 
        (y));''; and
                    (B) by adding at the end the following:
    ``(y) For purposes of this title, the term `oral health services' 
means--
            ``(1) relief of pain and infections;
            ``(2) restoration or replacement of teeth;
            ``(3) periodontal treatment;
            ``(4) adult fluoride application;
            ``(5) in-patient and out-patient dental surgical, 
        evaluation, and examination services;
            ``(6) denture or partial denture care;
            ``(7) per patient house call and nursing facility or 
        skilled nursing facility visits; and
            ``(8) such other dental health preventative services as the 
        Secretary determines, in consultation with national 
        professional dental groups, are necessary for treating and 
        preventing oral health diseases and maintenance of oral 
        health.''.
            (2) Conforming amendments.--
                    (A) Section 1902(a)(43)(D)(iii) of the Social 
                Security Act (42 U.S.C. 1396a(a)(43)(D)(iii)) is 
                amended by striking ``dental'' and inserting ``oral 
                health''.
                    (B) Section 1919(b)(4)(A)(vi) of such Act (42 
                U.S.C. 1396r(b)(4)(A)(vi)) is amended by striking 
                ``dental'' each place it appears and inserting ``oral 
                health''.
                    (C) Section 1927(k)(3)(C) of such Act (42 U.S.C. 
                1396r-8(k)(3)(C)) is amended by striking ``Dental'' and 
                inserting ``Oral health''.
    (c) Conforming Amendments.--
            (1) Definition of epsdt.--Section 1905(r)(3) of the Social 
        Security Act (42 U.S.C. 1396d(r)(3)) is amended--
                    (A) in the matter preceding subparagraph (A), by 
                striking ``dental'' and inserting ``oral health'';
                    (B) in subparagraph (A)(ii), by striking ``and'' at 
                the end;
                    (C) in subparagraph (B), by striking the period and 
                inserting ``; and''; and
                    (D) by adding at the end the following:
                    ``(C) which, in the case of an aged, blind, or 
                disabled individual described in section 1936(b), 
                include oral health services (as defined in subsection 
                (y) which are provided--
                            ``(i) at intervals which meet reasonable 
                        standards of dental practice (taking into 
                        account the increased needs and oral health 
                        complexities of this vulnerable population), as 
                        determined by the Secretary after consultation 
                        with national professional dental groups; and
                            ``(ii) at such other intervals to determine 
                        the existence of, or to treat, a suspected 
                        illness or condition.''.
            (2) State plan.--Section 1902(a) of such Act (42 U.S.C. 
        1396a(a)) is amended--
                    (A) in paragraph (66), by striking ``and'' at the 
                end:
                    (B) in paragraph (67), by striking the period and 
                inserting ``; and''; and
                    (C) by inserting after paragraph (67), the 
                following:
            ``(68) provide for--
                    ``(A) making oral health services available to 
                aged, blind, or disabled individuals described in 
                subsection (b) of section 1936 in accordance with the 
                requirements of that section;
                    ``(B) informing all persons in the State who are 
                aged, blind, or disabled and have been determined to be 
                eligible for medical assistance including oral health 
                services described in section 1905(y), of the 
                availability of such services;
                    ``(C) providing or arranging for the provision of 
                such services in all cases where they are requested;
                    ``(D) arranging for (directly or through referral 
                to appropriate agencies, organizations, or individuals) 
                corrective treatment the need for which is disclosed by 
                such services, and
                    ``(E) reporting to the Secretary (in a uniform form 
                and manner established by the Secretary, by aged, 
                blind, or disabled group and by basis of eligibility 
                for medical assistance, and by not later than April 1 
                after the end of each fiscal year, beginning with 
                fiscal year 2006) the information relating to oral 
                health services provided under the plan during each 
                fiscal year consisting of--
                            ``(i) the number of aged, blind, or 
                        disabled individuals who reside in the State;
                            ``(ii) the number of aged, blind, or 
                        disabled individuals provided oral health 
                        services;
                            ``(iii) the number of such individuals 
                        referred for corrective treatment (the need for 
                        which is disclosed by such services);
                            ``(iv) the amount of, and type of, 
                        preventive services needed and provided;
                            ``(v) the amount of, and type of, surgical 
                        restorative services needed and provided;
                            ``(vi) the amount of, and type of, other 
                        services needed and provided, disaggregated 
                        into whether the services were--
                                    ``(I) emergency;
                                    ``(II) preventive;
                                    ``(III) surgical;
                                    ``(IV) restorative;
                                    ``(V) periodontal;
                                    ``(VI) endodontic; or
                                    ``(VII) prosthodontic; and
                            ``(vii) the State's results in attaining 
                        the participation goals set for the State under 
                        section 1905(r) with respect to the provision 
                        of such services.''.
            (3) Federal medical assistance percentage.--Section 1905(b) 
        of such Act (42 U.S.C. 1396d(b)) is amended in the first 
        sentence, by striking ``section 1933(d)'' and inserting 
        ``sections 1933(d) and 1936(c)''.
            (4) Nursing facilities.--Section 1919(b)(4)(A)(vi) of such 
        Act (42 U.S.C. 1396r(b)(4)(A)(vi)) is amended by inserting ``, 
        oral health services (as defined in section 1905(y)) for an 
        aged, blind, or disabled individual described in section 
        1936(b) who is a resident of the nursing facility,'' after 
        ``plan)''.
    (d) Effective Date.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section shall apply to calendar 
        quarters beginning on or after October 1, 2006, without regard 
        to whether or not final regulations to carry out such 
        amendments have been promulgated by such date.
            (2) Delay permitted for state plan amendment.--In the case 
        of a State plan for medical assistance under title XIX of the 
        Social Security Act which the Secretary of Health and Human 
        Services determines requires State legislation (other than 
        legislation appropriating funds) in order for the plan to meet 
        the additional requirements imposed by the amendments made by 
        this section, the State plan shall not be regarded as failing 
        to comply with the requirements of such title solely on the 
        basis of its failure to meet these additional requirements 
        before the first day of the first calendar quarter beginning 
        after the close of the first regular session of the State 
        legislature that begins after the date of enactment of this 
        Act. For purposes of the previous sentence, in the case of a 
        State that has a 2-year legislative session, each year of such 
        session shall be deemed to be a separate regular session of the 
        State legislature.
                                 <all>