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:

1936.

Oral health services for children and aged, blind, or disabled individuals

(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 groupsrecognized dental organizations; 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.