1.
(a)This Act may be cited as the Special Care Dentistry Act of
2011
.
(b)Congress
finds the following:
(1)According to the
United States Surgeon General’s Report on Oral Health in America:
(A)No less than a
silent epidemic of oral diseases is affecting our most vulnerable citizens,
including low income elderly, individuals with disabilities, and many members
of racial and ethnic minority groups.
(B)Oral diseases and
conditions affect health and well-being throughout life. The burden of oral
problems is extensive and may be particularly severe in vulnerable
populations.
(C)Oral diseases and
conditions are associated with other health problems. Associations between
chronic oral infections and other health problems, including diabetes, heart
disease, and adverse pregnancy outcomes have been reported.
(2)Providing
appropriate and necessary oral health benefits under Medicaid to individuals
classified as aged, blind, or disabled would prevent unnecessary emergency room
visits, hospitalizations, and downstream health care costs, reducing Medicaid
spending.
(3)While 28 percent
of the people enrolled in Medicaid are aged, blind, or disabled, the high cost
of medical expenditures for these populations consumes 72 percent of the total
Medicaid budget. This is not the case with dental benefits.
(4)For the aged,
blind, or disabled, oral health services are deemed optional
by
the Federal Government and most States provide little to no Medicaid coverage
for these services. Many of these vulnerable citizen’s mouths are infected with
no hope of receiving access to even basic dental care.
(5)In 2003, adult
aged, blind, and disabled Medicaid recipients received basic oral health
services in only 6 States (Connecticut, New Jersey, New York, North Dakota,
Pennsylvania, and Wisconsin).
(6)Appropriate and
necessary oral health services for adult aged, blind, and disabled people will
help reduce not only Medicaid costs for these populations, but also downstream
Medicare expenditures, which together total almost $600,000,000,000
annually.
(7)Dental office
overhead averages over 65 percent. Unfortunately, Medicaid reimbursement rates
fall far short of covering these expenses.
(8)Additional Federal
investment for the delivery of oral health services is needed to ensure
vulnerable adults receive oral health benefits.
(9)Investments are
needed for an oral health initiative to reduce the profound disparities in oral
health by improving the health status of vulnerable populations to the level of
health status that is enjoyed by the majority of Americans.
2.Requirement to
provide aged, blind, or disabled individuals with oral health services under
the Medicaid program
(a)Title XIX of the Social Security Act (42 U.S.C. 1396 et
seq.) is amended by inserting after section 1943 the following new
section:
1944.Oral health services for aged, blind, or disabled
individuals(a)Services under a State
adult dental program for aged, blind, or disabled individualsA State shall provide oral health coverage
for aged, blind, or disabled individuals described in subsection (b) through a
separate State adult dental program. The State shall demonstrate that the
services and fees provided and program requirements under this section 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, and that the services are provided at intervals to determine the
existence of a suspected illness or condition consistent with reasonable
standards of dental practice (taking into account the increased needs and oral
health complexities of the population) as determined by the Secretary after
consultation with national professional dental organizations.
(b)Aged, blind, or
disabled individuals describedFor 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); and
(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)The
State shall provide transportation for 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 children eligible for
medical
assistance.
.
(b)Definition of
oral health services
(1)Section 1905 of the Social Security Act (42 U.S.C. 1396d)
is amended—
(A)in subsection (a),
by amending paragraph (10) to read as follows:
(10)oral health services (as defined in
subsection (ee)); and
;
and
(B)by adding at the
end the following:
(ee)(1)For purposes of this
title, the term oral health services means—
(A)relief of pain and infections;
(B)restoration or replacement of
teeth;
(C)periodontal treatment;
(D)dental health preventive services,
including adult fluoride application;
(E)in-patient and out-patient dental
surgical, evaluation, and examination services;
(F)dentures or partial denture
care;
(G)per patient house call and long term
care facility visits;
(H)sedation and anesthesia; and
(I)behavior management services.
(2)For the purpose of this subsection:
(A)The term long term care
facility means—
(i)a nursing facility;
(ii)an assisted living facility or a
resident care program facility (as such terms are defined by the
Secretary);
(iii)a board and care facility (as
defined in section 1903(q)(4)(B), including a mental retardation group
home);
(iv)an intermediate care facility for
the mentally retarded; and
(v)any other facility that is licensed
or certified by the State and is determined appropriate by the Secretary, such
as a community mental health center that meets the requirements of section
1913(c) of the Public Health Service Act, a psychiatric health facility, and a
mental health rehabilitation center.
(B)The term house call means
the delivery of dental services in long term care facilities needed to overcome
mobility impairments and transportation barriers.
(C)The term behavior
management means services needed to accommodate physical or behavioral
impairment.
.
(c)
(1)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
each place it appears.
(2)Section 1902(a) of such Act (42 U.S.C. 1396a(a)) is
amended—
(A)in paragraph (82),
by striking and
at the end;
(B)in paragraph (83),
by striking the period at the end and inserting ; and
;
and
(C)by inserting after
paragraph (83) the following:
(84)provide for—
(A)making oral health
services available to aged, blind, or disabled individuals described in
subsection (b) of section 1944 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 (as
defined in section 1905(ee)), 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 2012) 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 oral health services needed and provided;
(v)the amount of, and
type of, surgical restorative oral health services needed and provided;
and
(vi)the amount of,
and type of, other oral health 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.
.
(3)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(ee)) for an aged, blind, or disabled individual
described in section 1944(b) who is a resident of the nursing facility,
after plan)
.
(d)Federal funding
for cost of covering aged, blind, or disabledSection 1905 of the
Social Security Act (42 U.S.C. 1396d), as amended by subsection (b)(1), is
amended—
(1)in subsection (b),
in the first sentence, by inserting “subsection (ee) and” before “section
1933(d)”; and
(2)by adding at the
end the following new subsection:
(ff)Increased FMAP
for medical assistance for aged, blind, and disabled individualsThe Federal medical assistance percentage
determined for a State that is one of the 50 States or the District of Columbia
for each fiscal year with respect to amounts expended for medical assistance
for aged, blind and disabled individuals described in section 1944(b) shall be
equal to 100
percent.
.
(e)
(1)Except as provided in paragraph (2), the amendments made
by this section shall apply to calendar quarters beginning on or after October
1, 2011, 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 amendmentIn 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.