Section 1 Short title
This Act may be cited as the “Medicaid Dental Benefit Act”.
Medicaid Dental Benefit Act
A BILL
To amend title XIX of the Social Security Act to improve coverage of adult oral health care under the Medicaid program, and for other purposes.
Sec. 2 Requiring coverage of oral health services for adults under the Medicaid program
In general—
Mandatory coverage—
In general—
Requirement— Section 1902(a)(10)(A) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended by inserting “(10),” after “(5),”.
Effective date— The amendment made by clause (i) shall apply with respect to medical assistance furnished in calendar quarters beginning on or after the date that is 1 year after the date of the enactment of this Act.
Benchmark coverage— Section 1937(b)(5) of the Social Security Act (42 U.S.C. 1396u–7(b)(5)) is amended by striking the period and inserting “, and, beginning with the first quarter beginning on or after the date that is 1 year after the date of the enactment of the Medicaid Dental Benefit Act, coverage of dental and oral health services (as defined in section 1905(jj)).”.
in subsection (a)(10), by striking “dental services” and inserting “dental and oral health services (as defined in subsection (jj))”; and
by adding at the end the following new subsection:
“(jj) Definition of dental and oral health services
“(1) In general—For purposes of this title, the term “dental and oral health services” means services necessary to prevent disease and promote oral health, restore oral structures to health and function, reduce oral pain, and treat emergency oral conditions. Such term includes the services specified in paragraph (2).
“(2) Specified services—For purposes of paragraph (1), the services specified in this paragraph are the following:
“(A) Routine diagnostic and preventive care (such as dental cleanings, exams, and x-rays).
“(B) Basic dental services (such as fillings and extractions) and major dental services (such as root canals, crowns, and dentures).
“(C) Emergency dental care.
“(D) Temporomandibular (TMD) and orofacial pain disorder treatment.
“(E) Other necessary services related to dental and oral health (as specified by the Secretary).”
Enhanced FMAP; maintenance of effort—
Medicaid— Section 1905 of the Social Security Act (42 U.S.C. 1396d), as amended by subsection (a), is further amended—
in subsection (b), by striking “and (ii)” and inserting “(ii), and (kk)”; and
by adding at the end the following new subsection:
“(kk) Increased FMAP for expenditures for dental and oral health services
“(1) In general—The Federal medical assistance percentage with respect to amounts expended by such State for medical assistance consisting of dental and oral health services (as defined in subsection (jj)) furnished during the first calendar quarter beginning on or after the date that is 1 year after the date of the enactment of this subsection (or during any subsequent quarter) to individuals 21 years of age or older shall be equal to, in the case of such services furnished—
“(A) during the 3-year period beginning on the first day of such first calendar quarter, 100 percent;
“(B) during the 1-year period immediately following the period described in subparagraph (A), 95 percent;
“(C) during each subsequent 1-year period (through the third such subsequent period), the percentage specified under this paragraph for the preceding 1-year period, reduced by 5 percentage points; and
“(D) during any quarter beginning after the 7-year period beginning on the first day described in subparagraph (A), 80 percent.
“(2) No reduction in FMAP—Paragraph (1) shall not apply with respect to amounts expended by a State if the Federal medical assistance percentage otherwise applicable to such amounts without application of such paragraph would be higher than such percentage applicable to such amounts with application of such paragraph.”
Exclusion of amounts attributable to increased FMAP from territorial caps— Section 1108 of the Social Security Act (42 U.S.C. 1308) is amended—
in subsection (f), in the matter preceding paragraph (1), by striking “subsections (g) and (h)” and inserting “subsections (g), (h), and (i)”; and
by adding at the end the following:
“(i) Exclusion from caps of amounts attributable to increased FMAP for coverage of dental and oral health services—Any payment made to a territory for expenditures for medical assistance that are subject to an increase the Federal medical assistance percentage applicable to such expenditures under section 1905(kk) shall not be taken into account for purposes of applying payment limits under subsections (f) and (g) to the extent that such payment exceeds the amount of the payment that would have been made to the territory for such expenditures without regard to such section.”
Sec. 3 Adult oral health quality and equity measures
In general— Title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is amended by inserting after section 1139B the following new section:
“1139C. Adult oral health quality and equity measures
“(a) Development of core set of adult oral health care quality and equity measures
“(1) In general—The Secretary shall identify and publish a recommended core set of health quality and equity measures for individuals enrolled in a State plan (or waiver of such plan) under title XIX who are over the age of 21 in the same manner as the Secretary identifies and publishes a core set of child health quality measures under section 1139A, including with respect to identifying and publishing existing oral health quality measures for such individuals that are in use under public and privately sponsored health care coverage arrangements, or that are part of reporting systems that measure both the presence and duration of health insurance coverage over time, that may be applicable to enrolled adults.
“(2) Alignment with existing core set—In identifying and publishing the recommended core set of adult oral health quality and equity measures required under paragraph (1), the Secretary shall ensure that, to the extent possible, such measures align with and do not duplicate the core set of adult health quality and equity measures identified, published, and revised under section 1139B.
“(3) Process for adult oral health quality and equity measures program—In identifying gaps in existing adult oral health quality and equity measures and establishing priorities for the development and advancement of such measures, the Secretary shall consult with—
“(A) States;
“(B) health care providers;
“(C) patient representatives;
“(D) dental professionals; and
“(E) national organizations with expertise in oral health quality or equity measurement.
“(b) Deadlines
“(1) Recommended measures—Not later than 1 year after enactment of this Act, the Secretary shall identify and publish for comment a recommended core set of adult oral health quality and equity measures that includes the following:
“(A) Measures of utilization of oral health and dental services across health care settings.
“(B) Measures that address the availability of oral evaluations during or following medical visits for enrolled adults.
“(C) Measures that address the incidence of emergency department visits for non-traumatic dental conditions.
“(D) Measures that address the availability and receipt of follow-up dental care after emergency department visits for non-traumatic dental conditions during pregnancy.
“(E) Measures that address the availability of counseling of enrolled adults aimed at improving oral health outcomes.
“(F) Measures that address the availability and receipt of care for beneficiaries who meet the medical necessity criteria for general anesthesia and intravenous sedation.
“(G) Measures that address screening and evaluation for caries risk and periodontitis and treatment for caries risk and periodontitis, including the following:
“(i) The percentage of enrolled adults who have caries risk documented in the reporting year involved.
“(ii) The percentage of enrolled adults who received a topical fluoride application or sealants based on an oral health risk assessment demonstrating the need for such application or sealants during the reporting year involved.
“(iii) The percentage of enrolled adults who received a comprehensive or periodic oral evaluation or a comprehensive periodontal evaluation during the reporting year involved.
“(iv) The percentage of enrolled adults with a history of periodontitis who received an oral prophylaxis, scaling or root planing, or periodontal maintenance visit at least 2 times during the reporting year involved.
“(v) The percentage of enrolled adults with diabetes who receive a comprehensive or periodic evaluation or a comprehensive periodontal evaluation during the reporting year involved.
“(vi) The percentage of enrolled adults who require tooth extraction during the reporting year involved.
“(vii) The percentage of enrolled adults who require partial or full dentures during the reporting year involved.
“(2) Dissemination—Not later than 1 year after enactment of this Act, the Secretary shall publish an initial core set of oral health quality and equity measures that are applicable to enrolled adults.
“(3) Standardized reporting—Not later than 2 years after the date of the enactment of this Act, the Secretary, in consultation with States, shall develop a standardized format for the collection and reporting of information based on the initial core set of adult oral health quality and equity measures (stratified by race, ethnicity, primary language, disability status, sexual orientation and gender identity) and create guidelines, procedures, and incentives to States to use such measures and to collect and report information regarding the quality and equity of oral health care for enrolled adults.
“(4) Reports to Congress—Not later than 3 years after enactment of this act, and every 3 years thereafter, the Secretary shall include in the report to Congress required under section 1139A(a)(6) information similar to the information required under that section with respect to the measures established under this section.
“(c) Annual state reports regarding state-Specific oral health quality and equity measures applied under medicaid
“(1) In general—Each State with a plan approved under title XIX (or with a waiver of such plan in effect) shall annually report (separately or as part of the annual report required under section 1139A(c)) to the Secretary on—
“(A) the State-specific adult oral health quality and equity measures applied by the State under such a plan or waiver, including measures described in subsection (b)(1);
“(B) the State-specific information on the quality and equity of oral health care furnished to enrolled adults under such a plan or waiver, including information collected through external quality reviews of managed care organizations under section 1932 and benchmark plans under section 1937, disaggregated by race, ethnicity, primary language, disability status, sexual orientation, and gender identity;
“(C) the State-specific information regarding the dental benefits available to enrolled adults under such a plan or waiver, including any limits on such benefits and the amount of reimbursement provided under such plan or waiver for such benefits; and
“(D) the State-specific plan to identify, evaluate, and reduce in meaningful and measurable ways, to the extent practicable, health disparities based on age, sex, race, ethnicity, primary language, sexual orientation and gender identity, and disability status.
“(2) Publication—Not later than 2 years after the date of enactment of this Act, and annually thereafter, the Secretary shall collect, analyze, and make publicly available the information reported by States under paragraph (1).
“(d) Authorization of appropriations—There are authorized to be appropriated $10,000,000 to carry out this section. Funds appropriated under this subsection shall remain available until expended.”
Required reporting—
in paragraph (86), by striking “and” at the end;
in paragraph (87)(D), by striking the period and inserting “; and”; and
by inserting after paragraph (87) the following new paragraph:
“(88) provide for the reporting required under section 1139C(c).”
CHIP— Section 2102 of the Social Security Act (42 U.S.C. 1397bb) is amended by adding at the end the following new subsection:
“(d) Reporting requirements—A State child health plan shall provide for the reporting required under section 1139C(c).”
Sec. 4 Adult oral health care report
Not later than 2 years after the date of enactment of this Act, the Medicaid and CHIP Payment and Access Commission shall submit to Congress a report on issues related to adult oral health across the 50 States, tribes, and the territories, including—
the availability of adult oral health coverage, and enrollment in such coverage;
a survey of adult oral health status among low-income women of childbearing age;
barriers to accessing adult oral health care, including for racially diverse, ethnically diverse, and limited English proficient communities;
innovations and potential solutions to problems of access (including disparities in access) to adult oral health care, including innovations that would expand access to such care beyond dental offices; and
the impact of the amendments made by section 2 and recommendations for improving reimbursement rates for such provider of dental and oral health services under the Medicaid program.
Sec. 5 Oral health outreach and education
Not later than 1 year after the date of enactment of this Act, the Secretary shall develop a program, to be implemented through contracts with entities that fund or provide oral health care, to provide—
culturally competent and linguistically appropriate information on the availability and scope of oral health and dental coverage for adults who are eligible for or enrolled under a State plan (or waiver of such plan) under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.);
assistance in connecting adults and underserved populations enrolled in such a plan (or waiver) to oral health care;
education to dental, oral health, and medical professionals to strengthen core competencies in delivering culturally competent oral health care to adults enrolled in such a plan (or waiver), including: individuals with physical and intellectual disabilities, pregnant and postpartum individuals, Alaskan Native and American Indian populations, and people living in urban, rural and, other underserved communities; and
culturally competent and linguistically appropriate interactive oral health education aimed at promoting good oral health practices for adults, including racially and ethnically diverse Medicaid beneficiaries.