Coverage of dental services under the Medicare program

(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 at the end;(2)in subparagraph (HH), by striking the period at the end and inserting ; 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

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, 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).

(c)

Coverage of routine diagnostic and preventive care as a preventive service

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:

(D)Dental and oral health services described in paragraph (1) of subsection (lll), relating to routine diagnostic and preventive care.

(d)

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)by striking “and” before “(DD)”; and(B)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), other than those services described in paragraph (1) of such section), 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), 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 general

For 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 individuals

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.(3)

Limitations and Secretarial authority

(A)

Frequency

With 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 limitations

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.(ii)

Authority to modify coverage

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.(iii)

Authority to waive frequency limitations

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.

(e)

Payment under physician fee schedule

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)(II),.(f)

Dental prostheses

(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 inserting (including dental); and(B)by striking internal body.(2)

Special payment rules

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:

(23)

Payment and limits for dental prostheses

(A)

In general

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.(B)

Applicable percent

(i)

In general

For 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 individuals

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.(C)

Limitations and Secretarial authority

(i)

In general

Payment 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 limitations

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.(II)

Authority to modify coverage

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.(III)

Authority to waive frequency limitations

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

(g)

Repeal of ground for exclusion

Section 1862(a) of the Social Security Act (42 U.S.C. 1395y) is amended by striking paragraph (12).(h)

Effective date

The amendments made by this section shall apply to services furnished on or after January 1, 2022.