Dental and oral health care

(a)

Coverage

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— (1)in subparagraph (GG), by striking and after the semicolon at the end; (2)in subparagraph (HH), by striking the period at the end and adding ; and; and (3)by adding at the end the following new subparagraph:

(II)dental and oral health services (as defined in subsection (lll));

(b)

Dental and oral health services defined

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

(lll)

Dental and oral health services

(1)

In general

The term dental and oral health services means items and services (other than such items and services for which payment may be made under part A as inpatient hospital services) that are furnished during 2025 or a subsequent year, for which coverage was not provided under part B as of the date of the enactment of this subsection, and that are— (A)the preventive and screening services described in paragraph (2) furnished by a doctor of dental surgery or of dental medicine (as described in subsection (r)(2)) or an oral health professional (as defined in paragraph (4)); or (B)the basic treatments specified for such year by the Secretary pursuant to paragraph (3)(A) and the major treatments specified for such year by the Secretary pursuant to paragraph (3)(B) furnished by such a doctor or such a professional. (2)

Preventive and screening services

The preventive and screening services described in this paragraph are the following: (A)Oral exams. (B)Dental cleanings. (C)Dental x-rays performed in the office of a doctor or professional described in paragraph (1)(A). (D)Fluoride treatments. (3)

Basic and major treatments

For 2025 and each subsequent year, the Secretary shall specify— (A)basic treatments (which may include basic tooth restorations, basic periodontic services, tooth extractions, and oral disease management services); and (B)major treatments (which may include major tooth restorations, major periodontic services, bridges, crowns, and root canals);

that shall be included as dental and oral health services for such year.

(4)

Oral health professional

The term oral health professional means, with respect to dental and oral health services, a health professional who is licensed to furnish such services, acting within the scope of such license, by the State in which such services are furnished.

(c)

Payment; coinsurance; and limitations

(1)

In general

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended— (A)in subparagraph (N), by inserting and dental and oral health services (as defined in section 1861(lll)) after section 1861(hhh)(1)); (B)by striking and before (DD); and (C)by inserting before the semicolon at the end the following: , and (EE) with respect to dental and oral health services (as defined in section 1861(lll)), the amount paid shall be the payment amount specified under section 1834(z). (2)

Payment and limits specified

Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

(z)

Payment and limits for dental and oral health services

(1)

In general

The payment amount under this part for dental and oral health services (as defined in section 1861(lll)) shall be, subject to paragraph (3), the applicable percent (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. In determining such amounts determined under such payment basis, the Secretary shall consider payment rates paid to dentists for comparable services under State plans under title XIX, under the TRICARE program under chapter 55 of title 10 of the United States Code, and by other health care payers, such as Medicare Advantage plans under part C. (2)

Applicable percent

For purposes of paragraph (1), the applicable percent specified in this paragraph is, with respect to dental and oral health services (as defined in section 1861(lll)) furnished in a year— (A)that are preventive and screening services described in paragraph (2) or basic treatments specified for such year pursuant to paragraph (3)(A) of such section, 80 percent; and (B)that are major treatments specified for such year pursuant to paragraph (3)(B) of such section— (i)in the case such services are furnished during 2025, 10 percent; (ii)in the case such services are furnished during 2026 or a subsequent year before 2029, the applicable percent specified under this subparagraph for the previous year, increased by 10 percentage points; and (iii)in the case such services are furnished during 2029 or a subsequent year, 50 percent. (3)

Limitations

With respect to dental and oral health services that are— (A)preventive and screening oral exams, payment may be made under this part for not more than two such exams during a 12-month period; (B)dental cleanings, payment may be made under this part for not more than two such cleanings during a 12-month period; and (C)not described in subparagraph (A) or (B), payment may be made under this part only at such frequencies and under such circumstances determined appropriate by the Secretary.

(d)

Payment under physician fee schedule

(1)

In general

Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(II), before (3). (2)

Exclusion from MIPS

Section 1848(q)(1)(C)(ii) of the Social Security Act (42 U.S.C. 1395w–4(q)(1)(C)(ii)) is amended— (A)in subclause (II), by striking or at the end; (B)in subclause (III), by striking the period at the end and inserting ; or; and (C)by adding at the end the following new subclause:

(IV)with respect to 2025 and each subsequent year, is a doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)) or is an oral health professional (as defined in section 1861(lll)(4)).

(3)

Inclusion of oral health professionals as certain practitioners

Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clause:

(vii)With respect to 2025 and each subsequent year, an oral health professional (as defined in section 1861(lll)(4)).

(e)

Dentures

(1)

In general

Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)) is amended— (A)by striking (other than dental); and (B)by inserting and excluding dental, except for a full or partial set of dentures furnished on or after January 1, 2025 after colostomy care. (2)

Special payment rules

(A)

Limitations

Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph:

(6)

Special payment rule for dentures

Payment may be made under this part with respect to an individual for dentures— (A)not more than once during any 5-year period (except in the case that a doctor or professional described in section 1861(lll)(1)(A) determines such dentures do not fit the individual); and (B)only to the extent that such dentures are furnished pursuant to a written order of such a doctor or professional.

(B)

Application of competitive acquisition

(i)

In general

Section 1834(h)(1)(H) of the Social Security Act (42 U.S.C. 1395m(h)(1)(H)) is amended— (I)in the subparagraph heading, by inserting

, dentures

after

orthotics

; (II)by inserting , of dentures described in paragraph (2)(D) of such section, after 2011,; and (III)in clause (i), by inserting , such dentures after orthotics. (ii)

Conforming amendment

Section 1847(a)(2) of the Social Security Act (42 U.S.C. 1395w–3(a)(2)) is amended by adding at the end the following new subparagraph:

(D)

Dentures

Dentures described in section 1861(s)(8) for which payment would otherwise be made under section 1834(h).

(iii)

Exemption of certain items from competitive acquisition

Section 1847(a)(7) of the Social Security Act (42 U.S.C. 1395w–3(a)(7)) is amended by adding at the end the following new subparagraph:

(C)

Certain dentures

Those items and services described in paragraph (2)(D) if furnished by a physician or other practitioner (as defined by the Secretary) to the physician’s or practitioner’s own patients as part of the physician’s or practitioner’s professional service.

(f)

Exclusion modifications

Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended— (1)in paragraph (1)— (A)in subparagraph (O), by striking and at the end; (B)in subparagraph (P), by striking the semicolon at the end and inserting , and; and (C)by adding at the end the following new subparagraph:

(Q)in the case of dental and oral health services (as defined in section 1861(lll)) that are preventive and screening services described in paragraph (2) of such section, which are furnished more frequently than provided under section 1834(z)(3) and under circumstances other than circumstances determined appropriate under such section;

; and

(2)in paragraph (12), by inserting before the semicolon at the end the following: and except that payment may be made under part B for dental and oral health services that are covered under section 1861(s)(2)(II). (g)

Certain non-Application

(1)

In general

Paragraphs (1) and (4) of section 1839(a) of the Social Security Act (42 U.S.C. 1395r(a)) are amended by adding at the end of each such paragraphs the following: In applying this paragraph there shall not be taken into account benefits and administrative costs attributable to the amendments made by section 2 (other than subsection (g)) of the Medicare Dental Coverage Act of 2021 and the Government contribution under section 1844(a)(5).. (2)

Payment

Section 1844(a) of such Act (42 U.S.C. 1395w(a)) is amended— (A)in paragraph (4), by striking the period at the end and inserting ; plus; and (B)by adding at the end the following new paragraph:

(5)a Government contribution equal to the amount that is estimated to be payable for benefits and related administrative costs incurred that are attributable to the amendments made by section 2 (other than subsection (g)) of the Medicare Dental Coverage Act of 2021.

(h)

Implementation funding

(1)

In general

The Secretary of Health and Human Services (in this subsection referred to as the Secretary) shall provide for the transfer from the Federal Supplementary Medical Insurance Trust Fund under section 1841 of the Social Security Act (42 U.S.C. 1395t) to the Centers for Medicare & Medicaid Services Program Management Account of— (A)$20,000,000 for each of fiscal years 2022 through 2027 for purposes of implementing the amendments made by this section; and (B)such sums as determined appropriate by the Secretary for each subsequent fiscal year for purposes of administering the provisions of such amendments. (2)

Availability

Funds transferred pursuant to paragraph (1) shall remain available until expended.