[Congressional Record Volume 145, Number 59 (Wednesday, April 28, 1999)]
[Senate]
[Pages S4358-S4364]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN:
  S. 901. A bill to provide disadvantaged children with access to 
dental services; to the Committee on Health, Education, Labor, and 
Pensions.


            CHILDREN'S DENTAL HEALTH IMPROVEMENT ACT OF 1999

  Mr. BINGAMAN. Mr. President, I rise today to introduce a measure that 
is one cornerstone of a series of initiatives that are designed to help 
ensure that the fundamental needs of children in New Mexico and this 
country are met. This cornerstone, the Children's Dental Health 
Improvement Act of 1999, is built on the belief that children must have 
access to quality, affordable health care. A child who is sick cannot 
go to school, cannot be expected to learn, and cannot be expected to 
grow and thrive. For New Mexico, this is a particularly compelling need 
because according to the Children's Defense Fund, no state has a 
greater percentage of uninsured children than New Mexico. Specifically, 
the bill is designed to increase access to dental services for our 
children.

  Some will say: ``Why care about a few cavities in kids?'' In reality, 
this is a complex children's health issue. Chronically poor oral health 
is associated with growth and development problems in toddlers and 
compromises children's nutritional status. These children suffer great 
pain and cannot play or learn. It is estimated that lack of treatment 
for these children results in missed school days: an estimated 52 
million school hours annually. Their personal suffering is real. In 
reality, untreated dental problems get progressively worse and 
ultimately require more expensive interventions.
  Medicaid's Early and Periodic Screening Diagnosis and Treatment, or 
``EPSDT,'' program requires states to not only pay for a comprehensive 
set of

[[Page S4359]]

child health services, including dental services, but to assure 
delivery of those services. Unfortunately, low income children do not 
get the dental service they need. Despite the design of the Medicaid 
program to reach children and ensure access to routine dental care, the 
Inspector General of the Department of Health and Human Services 
reported in 1996 that only 18 percent of children eligible for Medicaid 
received even a single preventive dental service. The same report shows 
that no state provides preventive services to more than 50% of eligible 
children. Dentist participation is too low to assure access. We are 
falling short of our obligation to these children.
  In the past few months, I have had the opportunity to speak to many 
of New Mexico's rural health care providers and have learned that for 
New Mexico, the problem is of crisis proportions. Less than two percent 
of New Mexico's Medicaid dollars are used for children's oral health 
needs. My state alone projects a shortage of 157 dentists and 229 
dental hygienists. Children in New Mexico and elsewhere are showing up 
in emergency rooms for treatment of tooth abscesses instead of getting 
their cavities filled early on or having dental decay prevented in the 
first place.
  Tooth decay remains the single most common chronic disease of 
childhood and according to the Children's Dental Health Project, it 
affects more than half of all children by second grade. Tooth decay in 
children six years old is five to eight times more common than asthma 
which is often cited as the most common chronic disease of childhood.
  National data confirm that pediatric oral health in the U.S. is 
backsliding. Healthy People 2000 goals for dental needs of children 
will not be met. As this chart shows:
  52% of our 6 to 8 year olds have dental caries or cavities compared 
to 54% in 1986. Our goal was to decrease this to 35% by the year 2000; 
we have succeeded in a mere 2% change in this area.
  Additionally, we have slid backwards in some areas. The Healthy 
People 2000 oral health indicators show an increase in the percentage 
of children with untreated cavities. In 1986, 28% of our 6 to 8 year 
olds had untreated cavities compared to now when we find 31% of these 
children have untreated cavities.
  Tooth decay is increasingly a disease of low and modest income 
children. A substantial portion of decay in young children goes 
untreated. In fact, forty seven per cent of decay in children aged 2 
through 9, is untreated.
  The Children's Dental Health Improvement Act of 1999 is designed to 
attack the problem from many fronts. First, the bill addresses the 
issue of provider shortage by expanding opportunities for training 
pediatric dental health care providers. It allows for the Secretary to 
look at the reimbursement rates for dental providers as an incentive 
for dentists to participate in the Medicaid program so that we work 
toward increasing the actual care provided under the Medicaid program. 
Additionally, I have looked at the need for pediatric dental research 
to facilitate better approaches for care and it will put into place 
greater measures for surveillance of the problem. The bill would lead 
to increased accountability in the area of actual treatment once a 
problem is identified. Finally, I have included a section on health 
promotion and disease prevention to increase the number of children who 
have access to fluoridated water systems and dental sealants to prevent 
cavities.

  I recognize that this is an ambitious bill and that the issue of 
access to dental care for children covered by the Medicaid program is a 
complex one. I want to thank the various groups that have worked on the 
formulation of this legislation. In particular, I want to thank Drs. 
Burt Edelstein and Heber Simmons of the American Academy of Pediatric 
Dentistry for their hard work and excellent information. I also want to 
thank the American Association of Dental Schools, the American Dental 
Hygienist Association, the American Dental Association, the Hispanic 
Dental Association, the National Dental Association, and the American 
Association for Dental Research for their valuable input and I look 
forward to working with them all to ensure that we achieve increased 
access to oral health care for our children.
  I am committed to solving the problem of adequate access to dental 
care for our children and view this as a public health issue that has 
gone unnoticed for too long. I will welcome my colleagues to work with 
me to ensure that these children have healthy smiles instead of chronic 
pain from untreated problems.
  Mr. President, I ask unanimous consent to have the text of the 
Children's Dental Health Improvement Act of 1999 printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                 S. 901

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

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Children's 
     Dental Health Improvement Act of 1999''.
       (b) Table of Contents.--The table of contents for this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.

 TITLE I--EXPANDED OPPORTUNITIES FOR TRAINING PEDIATRIC DENTAL HEALTH 
                             CARE PROVIDERS

Sec. 101. Children's dental health training and demonstration programs.
Sec. 102. Increase in National Health Service Corps dental training 
              positions.
Sec. 103. Maternal and child health centers for leadership in pediatric 
              dentistry education.
Sec. 104. Dental officer multiyear retention bonus for the Indian 
              Health Service.
Sec. 105. Medicare payments to approved nonhospital dentistry residency 
              training programs; permanent dental exemption from 
              voluntary residency reduction programs.
Sec. 106. Dental health professional shortage areas.

  TITLE II--ENSURING DELIVERY OF PEDIATRIC DENTAL SERVICES UNDER THE 
                      MEDICAID AND SCHIP PROGRAMS

Sec. 201. Increased FMAP and fee schedule for dental services provided 
              to children under the medicaid program.
Sec. 202. Required minimum medicaid expenditures for dental health 
              services.
Sec. 203. Requirement to verify sufficient numbers of participating 
              dental health professionals under the medicaid program.
Sec. 204. Inclusion of recommended age for first dental visit in 
              definition of EPSDT services.
Sec. 205. Approval of final regulations implementing changes to EPSDT 
              services.
Sec. 206. Use of SCHIP funds to treat children with special dental 
              health needs.
Sec. 207. Grants to supplement fees for the treatment of children with 
              special dental health needs.
Sec. 208. Demonstration projects to increase access to pediatric dental 
              services in underserved areas.

                  TITLE III--PEDIATRIC DENTAL RESEARCH

Sec. 301. Identification of interventions that reduce the burden and 
              transmission of oral, dental, and craniofacial diseases 
              in high risk populations; development of approaches for 
              pediatric oral and craniofacial assessment.
Sec. 302. Agency for Health Care Policy and Research.
Sec. 303. Oral health professional research and training program.
Sec. 304. Consensus development conference.

               TITLE IV--SURVEILLANCE AND ACCOUNTABILITY

Sec. 401. CDC reports.
Sec. 402. Reporting requirements under the medicaid program.
Sec. 403. Administration on Children, Youth, and Families.
Sec. 404. Special supplemental food program for women, infants, and 
              children.

         TITLE V--ORAL HEALTH PROMOTION AND DISEASE PREVENTION

Sec. 501. Grants to increase resources for community water 
              fluoridation.
Sec. 502. Community water fluoridation.
Sec. 503. Community-based dental sealant program.

                        TITLE VI--MISCELLANEOUS

Sec. 601. Effective date.

     SEC. 2. FINDINGS.

       Congress makes the following findings:
       (1) The 1995 Institute of Medicine report on dental 
     education finds that oral health is an integral part of total 
     health, and is integral to comprehensive health, including 
     primary care.
       (2) Tooth decay is the most prevalent preventable chronic 
     disease of childhood and only the common cold, the flu, and 
     otitis media occur more often among young children.
       (3) Despite the design of the medicaid program to reach 
     children and ensure access to routine dental care, in 1996, 
     the Inspector

[[Page S4360]]

     General of the Department of Health and Human Services 
     reported that only 18 percent of children eligible for 
     medicaid received even a single preventive dental service.
       (4) The United States is facing a major dental health care 
     crisis that primarily affects the poor children of our 
     country, with 80 percent of all dental caries in children 
     found in the 20 percent of the population.
       (5) Low income children eligible for the medicaid program 
     and the State children's health insurance program experience 
     disproportionately high levels of oral disease.
       (6) The United States is not training enough pediatric 
     dental health care providers to meet the increasing need for 
     dental services for children.
       (7) The United States needs to increase access to health 
     promotion and disease prevention activities in the area of 
     oral health for children by increasing access to dental 
     health providers for children.
 TITLE I--EXPANDED OPPORTUNITIES FOR TRAINING PEDIATRIC DENTAL HEALTH 
                             CARE PROVIDERS

     SEC. 101. CHILDREN'S DENTAL HEALTH TRAINING AND DEMONSTRATION 
                   PROGRAMS.

       (a) In General.--Subpart 2 of part E of title VII of the 
     Public Health Service Act, as amended by the Health 
     Professions Education Partnerships Act of 1998 (Public Law 
     105-392) is amended by adding at the end the following:

     ``SEC. 771. CHILDREN'S DENTAL HEALTH PROGRAMS.

       ``(a) Training Program.--
       ``(1) In general.--The Secretary, acting through the Bureau 
     of Health Professions, shall develop training materials to be 
     used by health professionals to promote oral health through 
     health education.
       ``(2) Design.--The materials developed under paragraph (1) 
     shall be designed to enable health care professionals to--
       ``(A) provide information to individuals concerning the 
     importance of oral health;
       ``(B) recognize oral disease in individuals; and
       ``(C) make appropriate referrals of individuals for dental 
     treatment.
       ``(3) Distribution.--The materials developed under 
     paragraph (1) shall be distributed to--
       ``(A) accredited schools of the health sciences (including 
     schools for physician assistants, schools of medicine, 
     osteopathic medicine, dental hygiene, public health, nursing, 
     pharmacy, and dentistry), and public or private institutions 
     accredited for the provision of graduate or specialized 
     training programs in all aspects of health; and
       ``(B) health professionals and community-based health care 
     workers.
       ``(b) Demonstration Program.--
       ``(1) In general.--The Secretary shall make grants to 
     schools that train pediatric dental health providers to meet 
     the costs of projects--
       ``(A) to plan and develop new training programs and to 
     maintain or improve existing training programs in providing 
     dental health services to children; and
       ``(B) to assist dental health providers in managing complex 
     dental problems in children.
       ``(2) Administration.--
       ``(A) Amount.--The amount of any grant under paragraph (1) 
     shall be determined by the Secretary.
       ``(B) Application.--No grant may be made under paragraph 
     (1) unless an application therefore is submitted to and 
     approved by the Secretary. Such an application shall be in 
     such form, submitted in such manner, and contain such 
     information, as the Secretary shall by regulation prescribe.
       ``(C) Eligibility.--To be eligible for a grant under 
     subsection (a), the applicant must demonstrate to the 
     Secretary that it has or will have available full-time 
     faculty and staff members with training and experience in the 
     field of pediatric dentistry and support from other faculty 
     and staff members trained in pediatric dentistry and other 
     relevant specialties and disciplines such as dental public 
     health and pediatrics, as well as research.
       ``(c) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.''.
       (b) Authorization of Appropriations for General and 
     Pediatric Dentistry.--Section 747(e)(2)(A) of the Public 
     Health Service Act (42 U.S.C. 293k(e)(2)(A), as amended by 
     the Health Professions Education Partnerships Act of 1998 
     (Public Law 105-392) is amended in striking clause (iv) and 
     inserting the following:
       ``(iv) not less than $8,000,000 for awards of grants and 
     contracts under subsection (a) to programs of pediatric or 
     general dentistry.''.

     SEC. 102. INCREASE IN NATIONAL HEALTH SERVICE CORPS DENTAL 
                   TRAINING POSITIONS.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall 
     increase the number of dental health providers skilled in 
     treating children who become members of the Commissioned 
     Corps of the U.S. Health Service and who are assigned to duty 
     for the National Health Service Corps (referred to in this 
     section as the ``Corps'') under subpart II of part D of title 
     III of the Public Health Service Act (42 U.S.C. 254d et seq.) 
     so that there are at least 100 additional Commissioned Corps 
     dentists and dental hygienists in the Corps by 2001, at least 
     150 additional dentists and dental hygienists in the 
     Commissioned Corps by 2002, and at least 300 additional 
     dentists and dental hygienists in the Commissioner Corps by 
     2003.
       (b) Determination of Dental Site Readiness.--By not later 
     than January 1, 2001, the Secretary shall collaborate with 
     dental education institutions, State and local public health 
     dental officials and dental hygienist societies to determine 
     dental site readiness, specifically in inner city, rural, 
     frontier and border areas.
       (c) Report by Corps.--The Corps shall annually report to 
     Congress concerning how the Corps is meeting the oral health 
     needs of children in underserved areas, including rural, 
     frontier and border areas.
       (d) Loan Repayment Program.--The Secretary shall increase 
     the number of Corps dentists selected for loan repayments 
     under the provisions referred to in subsection (a) in a 
     sufficient number to address the demand for such repayment by 
     qualified dentists. The Secretary shall increase the number 
     of private practice dentists who contract with the Corps and 
     allow for such student loan repayment.
       (e) Pediatric Dentists.--The Secretary shall ensure that at 
     least 20 percent of the dentists in the Corps are pediatric 
     dentists and that another 20 percent of the dentists in the 
     Corps have general dentistry residency training.

     SEC. 103. MATERNAL AND CHILD HEALTH CENTERS FOR LEADERSHIP IN 
                   PEDIATRIC DENTISTRY EDUCATION.

       (a) Expansion of Training Programs.--The Secretary of 
     Health and Human Services shall, through the Bureau of Health 
     Professions, establish at least 10 Pediatric Dental Centers 
     of Excellence with not less than 36 additional training 
     positions annually for pediatric dentists at such centers of 
     excellence. The Secretary shall ensure that such training 
     programs are established in geographically diverse areas.
       (b) Definition.--In this section, the term `centers of 
     excellence' means a health professions school designated 
     under section 736 of the Public Health Service Act (42 U.S.C. 
     293).
       (c) Authorization of Appropriations.--There is authorized 
     to be appropriated, such sums as may be necessary to carry 
     out this section.

     SEC. 104. DENTAL OFFICER MULTIYEAR RETENTION BONUS FOR THE 
                   INDIAN HEALTH SERVICE.

       (a) Terms and Definitions.--In this section:
       (1) Dental officer.--The term ``dental officer'' means an 
     officer of the Indian Health Service designated as a dental 
     officer.
       (2) Director.--The term ``Director'' means the Director of 
     the Indian Health Service.
       (3) Creditable service.--The term ``creditable service'' 
     includes all periods that a dental officer spent in graduate 
     dental educational (GDE) training programs while not on 
     active duty in the Indian Health Service and all periods of 
     active duty in the Indian Health Service as a dental officer.
       (4) Residency.--The term ``residency'' means a graduate 
     dental educational (GDE) training program of at least 12 
     months leading to a speciality, including general practice 
     residency (GPR) or a 12-month advanced education general 
     dentistry (AEGD).
       (5) Specialty.--The term ``specialty'' means a dental 
     specialty for which there is an Indian Health Service 
     specialty code number.
       (b) Requirements for Bonus.--
       (1) In general.--An eligible dental officer of the Indian 
     Health Service who executes a written agreement to remain on 
     active duty for 2, 3, or 4 years after the completion of any 
     other active duty service commitment to the Indian Health 
     Service may, upon acceptance of the written agreement by the 
     Director, be authorized to receive a dental officer multiyear 
     retention bonus under this section. The Director may, based 
     on requirements of the Indian Health Service, decline to 
     offer such a retention bonus to any specialty that is 
     otherwise eligible, or to restrict the length of such a 
     retention bonus contract for a specialty to less than 4 
     years.
       (2) Limitations.--Each annual dental officer multiyear 
     retention bonus authorized under this section shall not 
     exceed the following:
       (A) $14,000 for a 4-year written agreement.
       (B) $8,000 for a 3-year written agreement.
       (C) $4,000 for a 2-year written agreement.
       (c) Eligibility.--
       (1) In general.--In order to be eligible to receive a 
     dental officer multiyear retention bonus under this section, 
     a dental officer shall--
       (A) be at or below such grade as the Director shall 
     determine;
       (B) have at least 8 years of creditable service, or have 
     completed any active duty service commitment of the Indian 
     Health Service incurred for dental education and training;
       (C) have completed initial residency training, or be 
     scheduled to complete initial residency training before 
     September 30 of the fiscal year in which the officer enters 
     into a dental officer multiyear retention bonus written 
     service agreement under this section; and
       (D) have a dental specialty in pediatric dentistry or oral 
     and maxillofacial surgery, or be a dental hygienist with a 
     minimum of a baccalaureate degree.
       (2) Extension to other officers.--The Director may extend 
     the retention bonus to dental officers other than officers 
     with a dental specialty in pediatric dentistry based on 
     demonstrated need. The criteria used as the basis for such an 
     extension shall be equitably determined and consistently 
     applied.

[[Page S4361]]

       (d) Termination of Entitlement to Special Pay.--The 
     Director may terminate at any time a dental officer's 
     multiyear retention bonus contract under this section. If 
     such a contract is terminated, the unserved portion of the 
     retention bonus contract shall be recouped on a pro rata 
     basis. The Director shall establish regulations that specify 
     the conditions and procedures under which termination may 
     take place. The regulations and conditions for termination 
     shall be included in the written service contract for a 
     dental officer multiyear retention bonus under this section.
       (e) Refunds.--
       (1) In general.--Prorated refunds shall be required for 
     sums paid under a retention bonus contract under this section 
     if a dental officer who has received the retention bonus 
     fails to complete the total period of service specified in 
     the contract, as conditions and circumstances warrant.
       (2) Debt to united states.--An obligation to reimburse the 
     United States imposed under paragraph (1) is a debt owed to 
     the United States.
       (3) No discharge in bankruptcy.--Notwithstanding any other 
     provision of law, a discharge in bankruptcy under title 11, 
     United States Code, that is entered less than 5 years after 
     the termination of a retention bonus contract under this 
     section does not discharge the dental officer who signed such 
     a contract from a debt arising under the contract or 
     paragraph (1).

     SEC. 105. MEDICARE PAYMENTS TO APPROVED NONHOSPITAL DENTISTRY 
                   RESIDENCY TRAINING PROGRAMS; PERMANENT DENTAL 
                   EXEMPTION FROM VOLUNTARY RESIDENCY REDUCTION 
                   PROGRAMS.

       (a) Medicare Payments To Approved Nonhospital Dentistry 
     Training Programs.--Section 1886 of the Social Security Act 
     (42 U.S.C. 1395ww) is amended by adding at the end the 
     following:
       ``(l) Payments For Nonhospital Based Dental Residency 
     Training Programs.--
       ``(1) In general.--Beginning January 1, 2000, the Secretary 
     shall make payments under this paragraph to approved 
     nonhospital based dentistry residency training programs 
     providing oral health care to children for the direct and 
     indirect expenses associated with operating such training 
     programs.
       ``(2) Payment amount.--
       ``(A) Methodology.--The Secretary shall establish 
     procedures for making payments under this subsection.
       ``(B) Total amount of payments.--In making payments to 
     approved non-hospital based dentistry residency training 
     programs under this subsection, the Secretary shall ensure 
     that the total amount of such payments will not result in a 
     reduction of payments that would otherwise be made under 
     subsection (h) or (k) to hospitals for dental residency 
     training programs.
       ``(C) Approved programs.--The Secretary shall establish 
     procedures for the approval of nonhospital based dentistry 
     residency training programs under this subsection.''.
       (b) Permanent Dental Exemption From Voluntary Residency 
     Reduction Programs.--
       (1) In general.--Section 1886(h)(6)(C) of the Social 
     Security Act (42 U.S.C. 1395ww(h)(6)(C)) is amended--
       (A) by redesignating clauses (i) through (iii) as 
     subclauses (I) through (III), respectively, and indenting 
     such subclauses (as so redesignated) appropriately;
       (B) by striking ``For purposes'' and inserting the 
     following:
       ``(i) In general.--Subject to clause (ii), for purposes''; 
     and
       (C) by adding at the end the following:
       ``(ii) Definition of `approved medical residency training 
     program'.--In this subparagraph, the term `approved medical 
     residency training program' means only such programs in 
     allopathic or osteopathic medicine.''.
       (2) Application to demonstration projects and authority.--
     Section 4626(b)(3) of the Balanced Budget Act of 1997 (42 
     U.S.C. 1395ww note) is amended by inserting ``in allopathic 
     or osteopathic medicine'' before the period.
       (c) Removal of Dentists from Full-Time Equivalent Count 
     Averaging Provisions.--
       (1) Medicare ime.--Section 1886(d)(5)(B)(vi) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(5)(B)(vi)) is amended by 
     adding at the end the following: ``The determination (based 
     on the 3-year average) described in subclause (II) shall 
     apply only to residents in the fields of allopathic medicine 
     and osteopathic medicine. All other residents shall be 
     counted based on the actual full-time equivalent resident 
     count for the cost-reporting period involved.''.
       (2) Medicare direct gme.--Section 1886(h)(4)(G)(i) of the 
     Social Security Act (42 U.S.C. 1395ww(h)(4)(G)(i)) is amended 
     by adding at the end the following: ``Such determination 
     (based on the 3-year average) shall apply only to residents 
     in the fields of allopathic medicine and osteopathic 
     medicine. All other residents shall be counted based on the 
     actual full-time equivalent resident count for the cost-
     reporting period involved.''.
       (d) Definition of Primary Care Resident.--Section 
     1886(h)(5)(H) of the Social Security Act (42 U.S.C. 
     1395ww(h)(5)(H)) is amended by striking ``or osteopathic 
     general practice'' and inserting ``osteopathic general 
     practice, general dentistry, advanced general dentistry, 
     pediatric dentistry, or dental public health''.
       (e) Effective Date.--
       (1) In general.--Except as provided in paragraph (2), the 
     amendments made by subsections (a), (c), and (d) take effect 
     on the date of enactment of this Act.
       (2) Exception.--The amendments made by subsection (b) shall 
     take effect as if included in the enactment of the Balanced 
     Budget Act of 1997.

     SEC. 106. DENTAL HEALTH PROFESSIONAL SHORTAGE AREAS.

       (a) Designation.--Section 332(a) of the Public Health 
     Service Act (42 U.S.C. 254e(a)) is amended by adding at the 
     end the following:
       ``(4)(A) In designating health professional shortage areas 
     under this section, the Secretary may designate certain areas 
     as dental health professional shortage areas if the Secretary 
     determines that such areas have a severe shortage of dental 
     health professionals. The Secretary shall develop, publish 
     and periodically update criteria to be used in designating 
     dental health professional shortage areas.
       ``(B) For purposes of this title a dental health 
     professional shortage area shall be considered to be a health 
     professional shortage area.''.
       ``(C) In subparagraph (A), the term `dental health 
     professional' includes general and pediatric dentists and 
     dental hygienists.''.
       (b) Loan Repayment Program.--Section 338B(b)(1)(A) of the 
     Public Health Service Act (42 U.S.C. 254l-1(b)(1)(A)) is 
     amended by inserting ``(including dental hygienists)'' after 
     ``profession''.
       (c) Technical Amendment.--Section 331(a)(2) of the Public 
     Health Service Act (42 U.S.C. 254d(a)(2)) is amended by 
     inserting ``(including dental health services)'' after 
     ``services''.
  TITLE II--ENSURING DELIVERY OF PEDIATRIC DENTAL SERVICES UNDER THE 
                      MEDICAID AND SCHIP PROGRAMS

     SEC. 201. INCREASED FMAP AND FEE SCHEDULE FOR DENTAL SERVICES 
                   PROVIDED TO CHILDREN UNDER THE MEDICAID 
                   PROGRAM.

       (a) Increased FMAP.--Section 1903(a)(5) of the Social 
     Security Act (42 U.S.C. 1396b(a)(5)) is amended--
       (1) by striking ``equal to 90 per centum'' and inserting 
     ``equal to--
       ``(A) 90 per centum'';
       (2) by inserting ``and'' after the semicolon; and
       (3) by adding at the end the following:
       ``(B) the greater of the Federal medical assistance 
     percentage or 75 per centum of the sums expended during such 
     quarter which are attributable to dental services for 
     children;''.
       (b) Fee Schedule.--Section 1902(a) of the Social Security 
     Act (42 U.S.C. 1396a(a)) is amended--
       (1) in paragraph (65), by striking the period and inserting 
     ``; and''; and
       (2) by inserting after paragraph (65) the following:
       ``(66) provide for payment under the State plan for dental 
     services for children at a rate that is designed to create an 
     incentive for providers of such services to treat children in 
     need of dental services (but that does not result in a 
     reduction or other adverse impact on the extent to which the 
     State provides dental services to adults).''.

     SEC. 202. REQUIRED MINIMUM MEDICAID EXPENDITURES FOR DENTAL 
                   HEALTH SERVICES.

       Section 1902(a) of the Social Security Act (42 U.S.C. 
     1396a(a)), as amended by section 201(b), is amended--
       (1) in paragraph (65), by striking ``and'' at the end;
       (2) in paragraph (66), by striking the period and inserting 
     ``; and''; and
       (3) by inserting after paragraph (66) the following:
       ``(67) provide that, beginning with fiscal year 2000--
       ``(A) not less than an amount equal to 7 percent of the 
     total annual expenditures under the State plan for medical 
     assistance provided to children will be expended during each 
     fiscal year for dental services for children (including the 
     prevention, screening, diagnosis, and treatment of dental 
     conditions); and
       ``(B) the State will not reduce or otherwise adversely 
     impact the extent to which the State provides dental services 
     to adults in order to meet the requirement of subparagraph 
     (A).''.

     SEC. 203. REQUIREMENT TO VERIFY SUFFICIENT NUMBERS OF 
                   PARTICIPATING DENTAL HEALTH PROFESSIONALS UNDER 
                   THE MEDICAID PROGRAM.

       Section 1902(a) of the Social Security Act (42 U.S.C. 
     1396a(a)), as amended by section 202, is amended--
       (1) in paragraph (66), by striking ``and'' at the end;
       (2) in paragraph (67), by striking the period and inserting 
     ``; and''; and
       (3) by inserting after paragraph (67) the following:
       ``(68) provide that the State will--
       ``(A) annually verify that the number of dental health 
     professionals (as defined in section 332(a)(4)(C) of the 
     Public Health Service Act) participating under the State 
     plan--
       ``(i) satisfies the minimum established degree of 
     participation of dental health professionals (as defined in 
     section 332(a)(4)(C) of the Public Health Service Act) to the 
     population of children in the State, as determined by the 
     Secretary in accordance with the criteria used by the 
     Secretary under section

[[Page S4362]]

     332(a)(4) of such Act (42 U.S.C. 254e(a)(4)) to designate a 
     dental health professional shortage area; and
       ``(ii) is sufficient to ensure that children enrolled in 
     the State plan have the same level of access to dental 
     services as the children residing in the State who are not 
     eligible for medical assistance under the State plan; and
       ``(B) collect data on the number of children being served 
     by dental health professionals as compared to the number of 
     children eligible to be served, and the actual services 
     provided.''.

     SEC. 204. INCLUSION OF RECOMMENDED AGE FOR FIRST DENTAL VISIT 
                   IN DEFINITION OF EPSDT SERVICES.

       Section 1905(r)(1)(A)(i) of the Social Security Act (42 
     U.S.C. 1396d(r)(1)(A)(i)) is amended by inserting ``and, with 
     respect to dental services under paragraph (3), in accordance 
     with guidelines for the age of a first dental visit that are 
     consistent with guidelines of the American Dental 
     Association, the American Dental Hygienist Association, the 
     American Academy of Pediatric Dentistry, and the Bright 
     Futures program of the Health Resources and Services 
     Administration of the Department of Health and Human 
     Services,'' after ``vaccines,''.

     SEC. 205. APPROVAL OF FINAL REGULATIONS IMPLEMENTING CHANGES 
                   TO EPSDT SERVICES.

       Not later than 30 days after the date of enactment of this 
     Act, the Secretary of Health and Human Services shall issue 
     final regulations implementing the proposed regulations based 
     on section 6403 of the Omnibus Budget Reconciliation Act of 
     1989 (Public Law 101-239; 103 Stat. 2262) that were contained 
     in the Federal Register issued for October 1, 1993.

     SEC. 206. USE OF SCHIP FUNDS TO TREAT CHILDREN WITH SPECIAL 
                   DENTAL HEALTH NEEDS.

       (a) In General.--Section 1905 of the Social Security Act 
     (42 U.S.C. 1396d) is amended--
       (1) in subsection (b), by striking ``or subsection (u)(3)'' 
     and inserting ``subsection (u)(3), or subsection (u)(4)''; 
     and
       (2) in subsection (u)--
       (A) by redesignating paragraph (4) as paragraph (5); and
       (B) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4)(A) For purposes of subsection (b), the expenditures 
     described in this paragraph are expenditures for medical 
     assistance described in subparagraph (B) for a low-income 
     child described in subparagraph (C), but only in the case of 
     such a child who resides in a State described in subparagraph 
     (D).
       ``(B) For purposes of subparagraph (A), the medical 
     assistance described in this subparagraph consists of the 
     following:
       ``(i) Dental services provided to children with special 
     oral health needs, including advanced oral, dental, and 
     craniofacial diseases and conditions.
       ``(ii) Outreach conducted to identify and treat children 
     with such special dental health needs.
       ``(C) For purposes of subparagraph (A), a low-income child 
     described in this subparagraph is a child whose family income 
     does not exceed 50 percentage points above the medicaid 
     applicable income level (as defined in section 2110(b)(4)).
       ``(D) A State described in this subparagraph is a State 
     that, as of August 5, 1997, has under a waiver authorized by 
     the Secretary or under section 1902(r)(2), established a 
     medicaid applicable income level (as defined in section 
     2110(b)(4)) for children under 19 years of age residing in 
     the State that is at or above 185 percent of the poverty line 
     (as defined in section 673(2) of the Community Services Block 
     Grant Act (42 U.S.C. 9902(2), including any revision required 
     by such section for a family of the size involved).''.
       (b) Effective Date.--The amendments made by this section 
     shall take effect as if included in the enactment of section 
     4911 of the Balanced Budget Act of 1997 (Public Law 105-33; 
     111 Stat. 570).

     SEC. 207. GRANTS TO SUPPLEMENT FEES FOR THE TREATMENT OF 
                   CHILDREN WITH SPECIAL DENTAL HEALTH NEEDS.

       Title V of the Social Security Act (42 U.S.C. 701 et seq.) 
     is amended by adding at the end the following:

     ``SEC. 511. GRANTS TO SUPPLEMENT FEES FOR THE TREATMENT OF 
                   CHILDREN WITH SPECIAL DENTAL HEALTH NEEDS.

       ``(a) Authority to Make Grants.--
       ``(1) In general.--In addition to any other payments made 
     under this title to a State, the Secretary shall award grants 
     to States to supplement payments made under the State 
     programs established under titles XIX and XXI for the 
     treatment of children with special oral health care needs.
       ``(2) Definition of children with special oral, dental, and 
     craniofacial health care needs.--In this section the term 
     `children with special oral health care needs' means children 
     with oral, dental and craniofacial conditions or disorders, 
     and other acute or chronic medical, genetic, and behavioral 
     disorders with dental manifestations.
       ``(b) Application of Other Provisions of Title.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     other provisions of this title shall not apply to a grant 
     made, or activities of the Secretary, under this section.
       ``(2) Exceptions.--The following provisions of this title 
     shall apply to a grant made under subsection (a) to the same 
     extent and in the same manner as such provisions apply to 
     allotments made under section 502(c):
       ``(A) Section 504(b)(4) (relating to expenditures of funds 
     as a condition of receipt of Federal funds).
       ``(B) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(C) Section 506 (relating to reports and audits, but only 
     to the extent determined by the Secretary to be appropriate 
     for grants made under this section).
       ``(D) Section 508 (relating to nondiscrimination).
       ``(c) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.''.

     SEC. 208. DEMONSTRATION PROJECTS TO INCREASE ACCESS TO 
                   PEDIATRIC DENTAL SERVICES IN UNDERSERVED AREAS.

       (a) Authority To Conduct Projects.--The Secretary of Health 
     and Human Services, through the Administrator of the Health 
     Care Financing Administration, the Administrator of the 
     Health Resources and Services Administration, the Director of 
     the Indian Health Service, and the Director of the Centers 
     for Disease Control and Prevention shall establish 
     demonstration projects that are designed to increase access 
     to dental services for children in underserved areas, as 
     determined by the Secretary.
       (b) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.
                  TITLE III--PEDIATRIC DENTAL RESEARCH

     SEC. 301. IDENTIFICATION OF INTERVENTIONS THAT REDUCE THE 
                   BURDEN AND TRANSMISSION OF ORAL, DENTAL, AND 
                   CRANIOFACIAL DISEASES IN HIGH RISK POPULATIONS; 
                   DEVELOPMENT OF APPROACHES FOR PEDIATRIC ORAL 
                   AND CRANIOFACIAL ASSESSMENT.

       (a) In General.--The Secretary of Health and Human 
     Services, through the Maternal and Child Health Bureau, the 
     Indian Health Service, and in consultation with the Agency 
     for Health Care Policy and Research and the National 
     Institutes of Health, shall--
       (1) support community based research that is designed to 
     improve our understanding of the etiology, pathogenesis, 
     diagnosis, prevention, and treatment of pediatric oral, 
     dental, craniofacial diseases and conditions and their 
     sequelae in high risk populations;
       (2) support demonstrations of preventive interventions in 
     high risk populations; and
       (3) develop clinical approaches to assess individual 
     patients for pediatric dental disease.
       (b) Authorization of Appropriations.--There is authorized 
     to be appropriated, such sums as may be necessary to carry 
     out this section.

     SEC. 302. AGENCY FOR HEALTH CARE POLICY AND RESEARCH.

       Section 902(a) of the Public Health Service Act (42 U.S.C. 
     299a(a)) is amended--
       (1) in paragraph (7), by striking ``and'' at the end;
       (2) in paragraph (8), by striking the period and inserting 
     ``; and''; and
       (3) by adding at the end the following:
       ``(9) the barriers that exist, including access to oral 
     health care for children, and the establishment of measures 
     of oral health status and outcomes.''.

     SEC. 303. ORAL HEALTH PROFESSIONAL RESEARCH AND TRAINING 
                   PROGRAM.

         Part G of title IV of the Public Health Service Act is 
     amended by inserting after section 487E (42 U.S.C. 288-5) the 
     following:

     ``SEC. 487F. ORAL HEALTH PROFESSIONAL RESEARCH AND TRAINING 
                   PROGRAM.

       ``(a) In General.--The Secretary, in consultation with the 
     Director of the National Institute of Dental and Craniofacial 
     Research, shall establish a program under which the Secretary 
     will enter into contracts with qualified oral health 
     professionals and such professionals will agree to conduct 
     research or provide training with respect to pediatric oral, 
     dental, and craniofacial diseases and conditions and in 
     exchange the Secretary will agree to repay, for each year of 
     service, not more than $35,000 of the principal and interest 
     of the educational loans of such professionals.
       ``(b) Qualified Oral Health Professional.--
       ``(1) Definition.--In this section, the term `qualified 
     oral health professional' includes dentists and allied dental 
     personnel serving in faculty positions.
       ``(2) Special preference.--In entering into contacts under 
     subsection (a), the Secretary shall give preference to 
     qualified oral health professionals--
       ``(A) who are serving, or who have served in research or 
     training programs of the National Institute of Dental and 
     Craniofacial Research; or
       ``(B) who are providing services at institutions that 
     provide oral health care to underserved pediatric populations 
     in rural or border areas.
       ``(c) Priorities.--The Secretary shall annually determine 
     the clinical and basic research and training priorities for 
     contracts under subsection (a), including dental caries, 
     orofacial accidents or traumas, birth defects

[[Page S4363]]

     such as cleft lip and palate and severe malocclusions, and 
     new techniques and approaches to treatment.
       ``(d) Contracts, Obligated Service, and Breach of 
     Contract.--The provisions of section 338B concerning 
     contracts, obligated service, and breach of contract, except 
     as inconsistent with this section, shall apply to contracts 
     under this section to the same extent and in the same manner 
     as such provisions apply to contracts under such section 
     338B.
       ``(e) Availability of Funds.--Amounts available for 
     carrying out this section shall remain available until the 
     expiration of the second fiscal year beginning after the 
     fiscal year for which such amounts were made available.''.

     SEC. 304. CONSENSUS DEVELOPMENT CONFERENCE.

       (a) In General.--Not later than April 1, 2000, the 
     Secretary of Health and Human Services, acting through the 
     National Institute of Child Health and Human Development and 
     the National Institute of Dental and Craniofacial Research, 
     shall convene a conference (to be known as the ``Consensus 
     Development Conference'') to examine the management of early 
     childhood caries and to support the design and conduct of 
     research on the biology and physiologic dynamics of 
     infectious transmission of dental caries. The Secretary shall 
     ensure that representatives of interested consumers and other 
     professional organizations participate in the Consensus 
     Development Conference.
       (b) Experts.--In administering the conference under 
     subsection (a), the Secretary of Health and Human Services 
     shall solicit the participation of experts in dentistry, 
     including pediatric dentistry, dental hygiene, public health, 
     and other appropriate medical and child health professionals.
       (c) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.
               TITLE IV--SURVEILLANCE AND ACCOUNTABILITY

     SEC. 401. CDC REPORTS.

       (a) Collection of Data.--The Director of the Centers for 
     Disease Control and Prevention in collaboration with other 
     organizations and agencies shall annually collect data 
     describing the dental, craniofacial, and oral health of 
     residents of at least 1 State from each region of the 
     Department of Health and Human Services.
       (b) Reports.--The Director shall compile and analyze data 
     collected under subsection (a) and annually prepare and 
     submit to the appropriate committees of Congress a report 
     concerning the oral health of certain States.

     SEC. 402. REPORTING REQUIREMENTS UNDER THE MEDICAID PROGRAM.

       Section 1902(a)(43)(D) of the Social Security Act (42 
     U.S.C. 1396a(43)(D)) is amended--
       (1) in clause (iii), by striking ``and'' and inserting 
     ``with the specific dental condition and treatment provided 
     identified,'';
       (2) in clause (iv), by striking the semicolon and inserting 
     a comma; and
       (3) by adding at the end the following:
       ``(v) the percentage of expenditures for such services that 
     were for dental services,
       ``(vi) the percentage of dental health professionals (as 
     defined in section 332(a)(4)(C) of the Public Health Service 
     Act) who are licensed in the State and provide services 
     commensurate with eligibility under the State plan, and
       ``(vii) collect and submit data on the number of children 
     being served as compared to the number of children who are 
     eligible for services, and the actual services provided;''.

     SEC. 403. ADMINISTRATION ON CHILDREN, YOUTH, AND FAMILIES.

       The Administrator of the Administration on Children, Youth, 
     and Families shall annually prepare and submit to the 
     appropriate committees of Congress a report concerning the 
     percentage of children enrolled in a Head Start or Early 
     Start program who have access to and who obtain dental care, 
     including children with special oral, dental, and 
     craniofacial health needs. The Administrator of the 
     Administration of Children, Youth and Families shall seek 
     methods to reestablish intraagency agreements with the 
     Administrator of the Health Resources and Services 
     Administration to address technical assistance for its 
     grantees in addressing access to preventive clinical 
     services.

     SEC. 404. SPECIAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, 
                   INFANTS, AND CHILDREN.

       Section 17(f) of the Child Nutrition Act of 1966 (42 U.S.C. 
     1786(f)) is amended by adding at the end the following:
       ``(25) The State shall collect and submit data on the 
     number of children being served under this section as 
     compared to the number of children who are eligible for 
     services, and the actual services provided.''.
         TITLE V--ORAL HEALTH PROMOTION AND DISEASE PREVENTION

     SEC. 501. GRANTS TO INCREASE RESOURCES FOR COMMUNITY WATER 
                   FLUORIDATION.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Director of the Division of Oral 
     Health of the Centers for Disease Control and Prevention, may 
     make grants to State or locality for the purpose of 
     increasing the resources available for community water 
     fluoridation.
       (b) Use of Funds.--A State shall use amounts provided under 
     a grant under subsection (a)--
       (1) to purchase fluoridation equipment;
       (2) to train fluoridation engineers; or
       (3) to develop educational materials on the advantages of 
     fluoridation.
       (c) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $25,000,000 for 
     fiscal year 2000, and such sums as may be necessary for each 
     subsequent fiscal year.

     SEC. 502. COMMUNITY WATER FLUORIDATION.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary''), acting 
     through the Director of the Indian Health Service and the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish a demonstration project that is designed to 
     assist rural water systems in successfully implementing the 
     Centers for Disease Control and Prevention water fluoridation 
     guidelines entitled ``Engineering and Administrative 
     Recommendations for Water Fluoridation'' (referred to in this 
     section as the ``EARWF'').
       (b) Requirements.--
       (1) Collaboration.--The Director of the Indian Health 
     Services shall collaborate with the Director of the Centers 
     for Disease Control and Prevention in developing the project 
     under subsection (a). Through such collaboration the 
     Directors shall ensure that technical assistance and training 
     are provided to tribal programs located in each of the 12 
     areas of the Indian Health Service. The Director of the 
     Indian Health Service shall provide coordination and 
     administrative support to tribes under this section.
       (2) General use of funds.--Amounts made available under 
     this section shall be used to assist small water systems in 
     improving the effectiveness of water fluoridation and to meet 
     the recommendations of the EARWF.
       (3) Fluoridation specialists.--
       (A) In general.--In carrying out this section, the 
     Secretary shall provide for the establishment of fluoridation 
     specialist engineering positions in each of the Dental 
     Clinical and Preventive Support Centers through which 
     technical assistance and training will be provided to tribal 
     water operators, tribal utility operators and other Indian 
     Health Service personnel working directly with fluoridation 
     projects.
       (B) Liaison.--A fluoridation specialist shall serve as the 
     principal technical liaison between the Indian Health Service 
     and the Centers for Disease Control and Prevention with 
     respect to engineering and fluoridation issues.
       (C) Cdc.--The Director of the Centers for Disease Control 
     and Prevention shall appoint individuals to serve as the 
     fluoridation specialists.
       (4) Implementation.--The project established under this 
     section shall be planned, implemented and evaluated over the 
     5-year period beginning on the date on which funds are 
     appropriated under this section and shall be designed to 
     serve as a model for improving the effectiveness of water 
     fluoridation systems of small rural communities.
       (c) Evaluation.--In conducting the ongoing evaluation as 
     provided for in subsection (b)(4), the Secretary shall ensure 
     that such evaluation includes--
       (1) the measurement of changes in water fluoridation 
     compliance levels resulting from assistance provided under 
     this section;
       (2) the identification of the administrative, technical and 
     operational challenges that are unique to the fluoridation of 
     small water systems;
       (3) the development of a practical model that may be easily 
     utilized by other tribal, State, county or local governments 
     in improving the quality of water fluoridation with emphasis 
     on small water systems; and
       (4) the measurement of any increased percentage of Native 
     Americans or Alaskan Natives who receive the benefits of 
     optimally fluoridated water.
       (d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $25,000,000 for 
     fiscal year 2000, and such sums as may be necessary for each 
     subsequent fiscal year.

     SEC. 503. SCHOOL-BASED DENTAL SEALANT PROGRAM.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Director of the Maternal and 
     Child Health Bureau of the Health Resources and Services 
     Administration, may award grants to States or localities to 
     provide for the development of school-based dental sealant 
     programs to improve the access of children to sealants.
       (b) Use of Funds.--A State shall use amounts received under 
     a grant under subsection (a) to provide funds to eligible 
     school-based entities or to public elementary or secondary 
     schools to enable such entities or schools to provide 
     children in second or sixth grade with access to dental care 
     and dental sealant services. Such services shall be provided 
     by licensed dental health professionals in accordance with 
     State practice licensing laws.
       (c) Eligibility.--To be eligible to receive funds under 
     this section an entity shall--
       (1) prepare and submit to the State an application at such 
     time, in such manner and containing such information as the 
     State may require; and
       (2) be a public elementary or secondary school--
       (A) that located in an urban area and in which and more 
     than 50 percent of the student population is participating in 
     Federal or State free or reduced meal programs; or
       (B) that is located in a rural area and, with respect to 
     the school district in which the school is located, the 
     district involved has a median income that is at or below 235 
     percent of the poverty line, as defined in section 673(2) of 
     the Community Services Block Grant Act (42 U.S.C. 9902(2)).

     Preference in awarding grants shall be provided to eligible 
     entities that use dental

[[Page S4364]]

     health care professionals in the most cost effective manner.
       (d) Coordination with Other Programs.--
       (1) In general.--An entity that receives funds from a State 
     under this section shall serve as an enrollment site for 
     purposes of enabling individuals to enroll in the State plan 
     under title XIX of the Social Security Act (42 U.S.C. 1396 et 
     seq.) or in the State Children's Health Insurance Program 
     under title XXI of such Act (42 U.S.C. 1397aa et seq.).
       (2) Conforming amendment.--Section 1920A(b)(3)(A)(i) of the 
     Social Security Act (42 U.S.C. 1396r-1a(b)(3)(A)(i)) is 
     amended--
       (A) by striking ``or (II)'' and inserting ``, (II)''; and
       (B) by inserting ``, or (III) is an eligible community-
     based entity or a public elementary or secondary school that 
     participates in the school-based dental sealant program 
     established under section 503 of the Children's Dental Health 
     Improvement Act of 1999'' before the semicolon.
       (e) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $5,000,000 for 
     fiscal year 2000, and such sums as may be necessary for each 
     subsequent fiscal year.
                        TITLE VI--MISCELLANEOUS

     SEC. 601. EFFECTIVE DATE.

       (a) In General.--Except as otherwise provided in this Act, 
     this Act and the amendments made by this Act take effect on 
     the date of enactment of this Act.
       (b) Extension of effective date for state law amendment.--
     In the case of a State plan under title XIX of the Social 
     Security Act which the Secretary of Health and Human Services 
     determines requires State legislation in order for the plan 
     to meet the additional requirements imposed by the amendments 
     made by this Act, the State plan shall not be regarded as 
     failing to comply with the requirements of such amendments 
     solely on the basis of its failure to meet the 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 the 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 the session is considered 
     to be a separate regular session of the State legislature.
                                 ______