Section 1 Short title
This Act may be cited as the “Strengthening Medicaid Incentives for Licensees Enrolled in Dental Act” or the “SMILED Act”.
Strengthening Medicaid Incentives for Licensees Enrolled in Dental Act
A BILL
To amend title XIX of the Social Security Act to improve oral health care and dental benefits under the Medicaid program, and for other purposes.
Sec. 2 Support for ensuring individuals enrolled in Medicaid have dental services access equal to the population of the State
Section 1903 of the Social Security Act (42 U.S.C. 1396b) is amended by adding at the end the following new subsection:
“(cc) Equal access to oral health care plan
“(1) Provider participation and access requirements—Not later than 1 year after the date of enactment of this paragraph, a State shall provide the Secretary with assurances that administrative barriers to the participation of licensed dentists under this title will be addressed, by—
“(A) improving eligibility verification;
“(B) ensuring that any such dentist may participate in a publicly funded plan without also having to participate in any other plan;
“(C) simplifying claims forms processing; and
“(D) assigning a single plan administrator for the dental program.
“(2) Study on dentist participation—Not later than 3 years after the date on which the assurance under paragraph (1) is submitted, each State shall conduct a study to determine whether the participation of licensed dentists have increased following the assurance provided under paragraph (1).”
Sec. 3 Dental and oral health services defined; audit requirement
Dental and oral health services defined— Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—
in subsection (a)(10), by inserting “and dental and oral health services (as defined in subsection (jj))” after “dental services”; and
by adding at the end the following new subsection:
“(jj) Dental and oral health services
“(1) In general—For purposes of subsection (a)(10), the term dental and oral health services means dentures and denture services, implants and implant services, and services necessary to prevent oral disease and promote oral health, restore oral structures to health and function, reduce oral pain, and treat emergency oral conditions, that are furnished by a provider who—
“(A) is legally authorized to furnish such items and services under State law (or the State regulatory mechanism provided by State law);
“(B) is initially credentialed by a State Medicaid program (or the designated entity of such program) through an integrated data collection system, as described in paragraph (3); and
“(C) is, as applicable, re-credentialed through such integrated data collection system by a State Medicaid program (or the designated entity of such program).
“(2) Selection of data collection system—Not later than one year after the date of enactment of this subsection, the State Medicaid Director shall select an integrated data collection system (as defined in paragraph (3) that—
“(A) minimizes provider paperwork burden; and
“(B) communicates final credentialing decisions to providers within 90 days of receipt of a completed application.
“(3) Integrated data collection system defined—For purposes of this subsection, the term integrated data collection system means an electronic system maintained by a State and used for purposes of enrolling, screening, and credentialing dentists under a State Medicaid program.”
Dental and oral health services audit requirement— Not later than 90 days after the date of enactment of this Act, a State Medicaid program, including a program offered by a sponsor of a Medicaid managed care plan, that offers dental and oral health services audits a claim for such dental and oral health services shall—
utilize a licensed health care professional from the dental specialty area of practice being audited to establish relevant audit methodology consistent with—
established practice guidelines, standards of care, and State-issued dental Medicaid provider handbooks; and
established clinical practice guidelines and acceptable standards of care established by the dental professional or specialty organizations responsible for setting such standards of care;
develop and implement, in consultation with the Centers for Medicare & Medicaid Services, a procedure in which an improper payment identified by an audit may be resubmitted as a claims adjustment, including the resubmission of—
claims denied as a result of an interpretation of scope of services not previously held by the Centers for Medicare & Medicaid Services;
documentation when the document provided is incomplete, illegible, or unclear; and
documentation when clerical errors resulted in a denial of claims for services actually provided; and
disallow the difference between the payment for the service that was provided and the payment for the service that should have been provided if a service was provided and sufficiently documented, but denied because it was determined that a different service should have been billed.