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Title VI — Providing for Dental, Vision, and Hearing Coverage under the Medicare program

H.R. 3 · 116th Congress · Dec 16, 2019 · Lineage

VI Providing for Dental, Vision, and Hearing Coverage under the Medicare program

Sec. 601 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 (kkk));”

(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:

“(kkk) 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);

“(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(kkk))” after “section 1861(hhh)(1))”;
(B)
by striking “and” before “(CC)”; and
(C)
by inserting before the semicolon at the end the following: “, and (DD) with respect to dental and oral health services (as defined in section 1861(kkk)), the amount paid shall be the payment amount specified under section 1834(x)”.
(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:

“(x) 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(kkk)) 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(kkk)) 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(kkk)(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(kkk)(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(kkk)(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(kkk)) that are preventive and screening services described in paragraph (2) of such section, which are furnished more frequently than provided under section 1834(x)(3) and under circumstances other than circumstances determined appropriate under such section;”

(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 601 (other than subsection (g)) of the Elijah E. Cummings Lower Drug Costs Now Act and the Government contribution under section 1844(a)(4)”.
(2)
Payment— Section 1844(a) of such Act (42 U.S.C. 1395w(a)) is amended—
(A)
in paragraph (3), by striking the period at the end and inserting “; plus”; and
(B)
by adding at the end the following new paragraph:

“(4) 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 601 (other than subsection (g)) of the Elijah E. Cummings Lower Drug Costs Now Act.”

(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 2020 through 2025 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 and additional use of funds— Funds transferred pursuant to paragraph (1) shall remain available until expended and may be used, in addition to the purpose specified in paragraph (1)(A), to implement the amendments made by sections 602 and 603.

Sec. 602 Providing coverage for hearing care under the Medicare program

(a)
Provision of aural rehabilitation and treatment services by qualified audiologists— Section 1861(ll)(3) of the Social Security Act (42 U.S.C. 1395x(ll)(3)) is amended by inserting “(and, beginning January 1, 2023, such aural rehabilitation and treatment services)” after “assessment services”.
(b)
Coverage of hearing aids—
(1)
Inclusion of hearing aids as prosthetic devices— Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)) is amended by inserting “, and including hearing aids furnished on or after January 1, 2023, to individuals diagnosed with profound or severe hearing loss” before the semicolon at the end.
(2)
Payment limitations for hearing aids— Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)), as amended by section 601(e)(2)(A), is further amended by adding at the end the following new paragraph:

“(7) Limitations for hearing aids—Payment may be made under this part with respect to an individual, with respect to hearing aids furnished on or after January 1, 2023—

“(A) not more than once during a 5-year period;

“(B) only for types of such hearing aids that are not over-the-counter hearing aids (as defined in section 520(q)(1) of the Federal Food, Drug, and Cosmetic Act) and that are determined appropriate by the Secretary; and

“(C) only if furnished pursuant to a written order of a physician or qualified audiologist (as defined in section 1861(ll)(4)(B)).”

(3)
Application of competitive acquisition—
(A)
In general— Section 1834(h)(1)(H) of the Social Security Act (42 U.S.C. 1395m(h)(1)(H)), as amended by section 601(e)(2)(B)(i), is further amended—
(i)
in the header, by inserting “, hearing aids” after “dentures”;
(ii)
by inserting “, of hearing aids described in paragraph (2)(E) of such section,” after “paragraph (2)(D) of such section”; and
(iii)
in clause (i), by inserting “, such hearing aids” after “such dentures”.
(B)
Conforming amendment—
(i)
In general— Section 1847(a)(2) of the Social Security Act (42 U.S.C. 1395w–3(a)(2)), as amended by section 601(e)(2)(B)(ii), is further amended by adding at the end the following new subparagraph:

“(E) Hearing aids—Hearing aids described in section 1861(s)(8) for which payment would otherwise be made under section 1834(h).”

(ii)
Exemption of certain items from competitive acquisition— Section 1847(a)(7) of the Social Security Act (42 U.S.C. 1395w–3(a)(7)), as amended by section 601(e)(2)(B)(iii), is further amended by adding at the end the following new subparagraph:

“(D) Certain hearing aids—Those items and services described in paragraph (2)(E) 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.”

(4)
Inclusion of audiologists as certain practitioners to receive payment on an assignment-related basis— Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by section 601(d)(4), is further amended by adding at the end the following new clause:

“(viii) With respect to 2023 and each subsequent year, a qualified audiologist (as defined in section 1861(ll)(4)(B)).”

(c)
Exclusion modification— Section 1862(a)(7) of the Social Security Act (42 U.S.C. 1395y(a)(7)) is amended by inserting “(except such hearing aids or examinations therefor as described in and otherwise allowed under section 1861(s)(8))” after “hearing aids or examinations therefor”.
(d)
Certain non-application—
(1)
In general— The last sentence of section 1839(a)(1) of the Social Security Act (42 U.S.C. 1395r(a)(1)), as added by section 601(g)(1), is amended by striking “section 601 (other than subsection (g))” and inserting “sections 601 (other than subsection (g)), 602 (other than subsection (d))”.
(2)
Payment— Paragraph (4) of section 1844(a) of such Act (42 U.S.C. 1395w(a)), as added by section 601(g)(2), is amended by striking “section 601 (other than subsection (g))” and inserting “sections 601 (other than subsection (g)), 602 (other than subsection (d))”.
(e)
Report; regulations—
(1)
Report— Not later than the date that is 3 years after the date of the enactment of this Act, the Inspector General of the Department of Health and Human Services shall conduct a study to assess (and submit to the Secretary of Health and Human Services a report on) any program integrity or overutilization risks with respect to allowing qualified audiologists (as defined in paragraph (4)(B) of 1861(ll) of the Social Security Act (42 U.S.C. 1395x(ll))) to furnish audiology services (as defined in paragraph (3) of such section) to individuals entitled to benefits under part A of title XVIII of such Act (42 U.S.C. 1395c et seq.) and enrolled for benefits under part B of such title (42 U.S.C.1395j et seq.) without such individuals being referred by a physician (as defined in section 1861(r) of such Act (42 U.S.C. 1395x(r))) or practitioner (as described in section 602.32 of title 42, Code of Federal Regulations) to such qualified audiologists. In conducting such study, the Inspector General may take into account experiences with audiologists furnishing audiology services to enrollees in other Federal programs, including in a health benefit plan under chapter 89 of title 5, United States Code or in health care benefits under the TRICARE program under chapter 55 of title 10 of the United States Code or under chapter 17 of title 38 of such Code.
(2)
Regulations— The Secretary of Health and Human Services may promulgate regulations to allow qualified audiologists (as so defined) to furnish audiology services (as so defined) without a referral from a physician or practitioner, consistent with the findings submitted to the Secretary pursuant to paragraph (1)(B).
(f)
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 2020 through 2024 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 and additional use of funds— Funds transferred pursuant to paragraph (1) shall remain available until expended and may be used, in addition to the purpose specified in paragraph (1)(A), to implement the amendments made by sections 601 and 603.

Sec. 603 Providing coverage for vision care under the Medicare program

(a)
Coverage— Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 601(a), is further amended—
(1)
in subparagraph (HH), by striking “and” after the semicolon at the end;
(2)
in subparagraph (II), by striking the period at the end and adding “; and”; and
(3)
by adding at the end the following new subparagraph:

“(JJ) vision services (as defined in subsection (lll));”

(b)
Vision services defined— Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 601(b), is further amended by adding at the end the following new subsection:

“(lll) Vision services—The term vision services means—

“(1) routine eye examinations to determine the refractive state of the eyes, including procedures performed during the course of such examination; and

“(2) contact lens fitting services;”

(c)
Payment limitations— Section 1834 of the Social Security Act (42 U.S.C. 1395m), as amended by section 601(c)(2), is further amended by adding at the end the following new subsection:

“(y) Limitation for vision services—With respect to vision services (as defined in section 1861(lll)) and an individual, payment may be made under this part for only 1 routine eye examination described in paragraph (1) of such section and 1 contact lens fitting service described in paragraph (2) of such section during a 2-year period.”

(d)
Payment under physician fee schedule— Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)), as amended by section 601(d)(1), is further amended by inserting “(2)(JJ),” before “(3)”.
(e)
Coverage of conventional eyeglasses and contact lenses— Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)), as amended by section 602(b)(1), is further amended by striking “, and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens” and inserting “, including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens, if furnished before January 1, 2023, including conventional eyeglasses or contact lenses, whether or not furnished subsequent to such a surgery, if furnished on or after January 1, 2024”.
(f)
Special payment rules for eyeglasses and contact lenses—
(1)
Limitations— Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)), as amended by section 601(e)(2)(A) and section 602(b)(2), is further amended by adding at the end the following new paragraph:

“(8) Payment limitations for eyeglasses and contact lenses

“(A) In general—With respect to eyeglasses and contact lenses furnished to an individual on or after January 1, 2023, subject to subparagraph (B), payment may be made under this part only—

“(i) during a 2-year period, for either 1 pair of eyeglasses (including lenses and frames) or not more than a 2-year supply of contact lenses that is provided in not more than 180-day increments;

“(ii) with respect to amounts attributable to the lenses and frames of such a pair of eyeglasses or amounts attributable to such a 2-year supply of contact lenses, in an amount not greater than—

“(I) for a pair of eyeglasses furnished in, or a 2-year supply of contact lenses beginning in, 2023—

“(aa) $85 for the lenses of such pair of eyeglasses and $85 for the frames of such pair of eyeglasses; or

“(bb) $85 for such 2-year supply of contact lenses; and

“(II) for the lenses and frames of a pair of eyeglasses furnished in, or a 2-year supply of contact lenses beginning in, a subsequent year, the dollar amounts specified under this subparagraph for the previous year, increased by the percentage change in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the previous year;

“(iii) for types of eyeglass lenses, and for types of contact lenses, as determined appropriate by the Secretary;

“(iv) if furnished pursuant to a written order of a physician described in section 1861(lll); and

“(v) if during the 2-year period described in clause (i), the individual did not already receive (as described in subparagraph (B)) one pair of conventional eyeglasses or contact lenses subsequent to a cataract surgery with insertion of an intraocular lens furnished during such period.

“(B) Exception—With respect to a 2-year period described in subparagraph (A)(i), in the case of an individual who receives cataract surgery with insertion of an intraocular lens, notwithstanding subparagraph (A), payment may be made under this part for one pair of conventional eyeglasses or contact lenses furnished subsequent to such cataract surgery during such period.”

(2)
Application of competitive acquisition—
(A)
In general— Section 1834(h)(1)(H) of the Social Security Act (42 U.S.C. 1395m(h)(1)(H)), as amended by section 601(e)(2)(B)(i) and section 602(b)(3)(A), is further amended—
(i)
in the header by inserting “, eyeglasses, and contact lenses” after “hearing aids”;
(ii)
by inserting “and of eyeglasses and contact lenses described in paragraph (2)(F) of such section,” after “paragraph (2)(E) of such section,”; and
(iii)
in clause (i), by inserting “, or such eyeglasses and contact lenses” after “such hearing aids”.
(B)
Conforming amendment—
(i)
In general— Section 1847(a)(2) of the Social Security Act (42 U.S.C. 1395w–3(a)(2)), as amended by section 601(e)(2)(B)(ii) and section 602(b)(3)(B)(i), is further amended by adding at the end the following new subparagraph:

“(F) Eyeglasses and contact lenses—Eyeglasses and contact lenses described in section 1861(s)(8) for which payment would otherwise be made under section 1834(h).”

(ii)
Exemption of certain items from competitive acquisition— Section 1847(a)(7) of the Social Security Act (42 U.S.C. 1395w–3(a)(7)), as amended by section 601(e)(2)(B)(iii) and section 602(b)(3)(B)(ii), is further amended by adding at the end the following new subparagraph:

“(E) Certain eyeglasses and contact lenses—Those items and services described in paragraph (2)(F) 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.”

(g)
Exclusion modifications— Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)), as amended by section 601(f), is further amended—
(1)
in paragraph (1)—
(A)
in subparagraph (P), by striking “and” at the end;
(B)
in subparagraph (Q), by striking the semicolon at the end and inserting “, and”; and
(C)
by adding at the end the following new subparagraph:

“(R) in the case of vision services (as defined in section 1861(lll)) that are routine eye examinations and contact lens fitting services (as described in paragraph (1) or (2), respectively, of such section), which are furnished more frequently than once during a 2-year period;”

(2)
in paragraph (7)—
(A)
by inserting “(other than such an examination that is a vision service that is covered under section 1861(s)(2)(JJ))” after “eye examinations”; and
(B)
by inserting “(other than such a procedure that is a vision service that is covered under section 1861(s)(2)(JJ))” after “refractive state of the eyes”.
(h)
Certain non-application—
(1)
In general— The last sentence of section 1839(a)(1) of the Social Security Act (42 U.S.C. 1395r(a)(1)), as added by section 601(g)(1) and amended by section 602(d)(1), is further amended by inserting “, and 603 (other than subsection (h))” after “602 (other than subsection (d))”.
(2)
Payment— Paragraph (4) of section 1844(a) of such Act (42 U.S.C. 1395w(a)), as added by section 601(g)(2) and amended by section 602(d)(2), is further amended by inserting “, and 603 (other than subsection (h))” after “602 (other than subsection (d))”.
(i)
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 2020 through 2024 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 and additional use of funds— Funds transferred pursuant to paragraph (1) shall remain available until expended and may be used, in addition to the purpose specified in paragraph (1)(A), to implement the amendments made by sections 601 and 602.