Sec. 402. Coverage of dental and oral health care
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Section 1861(s)(2) of the Social Security Act ( 42 U.S.C. 1395x(s)(2) ) is amended— in subparagraph (JJ), by striking and at the end; in subparagraph (KK), by inserting and after the semicolon; and by adding at the end the following new subparagraph: dental and oral health services (as defined in subsection (ooo)); . Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended by adding at the end the following new subsection: Except as provided in paragraph (2), the term dental and oral health services means the following items and services that are 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 (3)) on or after January 1, 2028 (or January 1, 2027, in the case of dentures):
Preventive and screening services, including oral exams, dental cleanings, dental x-rays, and fluoride treatments. Services to address oral disease, including services such as restorative services, prosthodontic and endodontic services, including fillings, bridges, crowns, and root canals, periodontal maintenance, periodontal scaling and root planing, tooth extractions, therapeutic pulpotomy, and other related items and services. Complete dentures, partial dentures, and implants, including related items and services.
Such term does not include items and services for which, as of the date of the enactment of this subsection, coverage was permissible under section 1862(a)(12) and cosmetic services not otherwise covered under section 1862(a)(10). The term oral health professional means, with respect to dental and oral health services, a health professional (other than a doctor of dental surgery or of dental medicine (as described in subsection (r)(2))) who is licensed to furnish such services, acting within the scope of such license, by the State in which such services are furnished. .
Section 1833(a)(1) of the Social Security Act ( 42 U.S.C. 1395l(a)(1) ) is amended— in subparagraph (N), by inserting and dental and oral health services (as defined in section 1861(ooo)) after section 1861(hhh)(1)) ; by striking and before
(HH); and by inserting before the semicolon at the end the following: and
(II)with respect to dental and oral health services (as defined in section 1861(ooo)), the amount paid shall be the payment amount specified under section 1834(bb) . Section 1834 of the Social Security Act ( 42 U.S.C. 1395m ) is amended by adding at the end the following new subsection: The payment amount under this part for dental and oral health services (as defined in section 1861(ooo)) shall be, subject to paragraphs
(3)and (4), 80 percent (or 100 percent, in the case of preventive and screening services described in section 1861(ooo)(1)(A)) of the lesser of— the actual charge for the service; or in the case of such services furnished by a doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)), the amount determined under the fee schedule established under paragraph (2); or in the case of such services furnished by an oral health professional (as defined in section 1861(ooo)(3)), 85 percent of the amount determined under the fee schedule established under paragraph (2). The Secretary shall establish a fee schedule for dental and oral health services furnished in 2028 (or 2027, in the case of dentures) and subsequent years. The fee schedule amount for a dental or oral health service shall be equal to 70 percent of the national median fee (as determined under subparagraph (B)) for the service or a similar service for the year (or, in the case of dentures, at the bundled payment amount under clause
(iv)of such subparagraph), adjusted by the geographic adjustment factor established under section 1848(e)(2) for the area for the year. In carrying out this paragraph, the Secretary shall consult annually with organizations representing dentists and other providers who furnish dental and oral health services and shall share with such providers the data and data analysis used to determine fee schedule amounts under this paragraph. For purposes of subparagraph (A), the Secretary shall apply the national median fee for a dental or oral health service for 2028 (or 2027, in the case of dentures) and subsequent years in accordance with this subparagraph. Except as provided in clause
(iii)and clause (iv), the national median fee for a dental or oral health service shall be equal to— for 2028 (or 2027, in the case of dentures), the median fee for the service in the table titled General Practitioners–National of the 2020 Survey of Dental Fees published by the American Dental Association, increased by the applicable percent increase for the year determined under subclause (II), as reduced by the productivity adjustment under subclause (III); and for 2029 (or 2028, in the case of dentures) and subsequent years, the amount determined under this subclause for the preceding year, updated pursuant to subparagraph (C)(i). The applicable percent increase determined under this subclause for a year is an amount equal to the percentage increase between— the consumer price index for all urban consumers (United States city average) ending with June of the previous year; and the consumer price index for all urban consumers (United States city average) ending with June of 2027 (or 2026, in the case of dentures). After determining the applicable percentage increase under subclause
(II)for a year, the Secretary shall reduce such percentage increase by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). If the Secretary determines there is insufficient data under the Survey described in clause
(ii)with respect to a dental or oral health service, the national median fee for the service for a year shall be equal to an amount established for the service using 1 or more of the following methods, as determined appropriate by the Secretary: The payment basis determined under section 1848. Fee schedules for dental and oral health services which shall include, as practicable, fee schedules— under Medicare Advantage plans under part C; under State plans (or waivers of such plans) under title XIX; and established by other health care payers. The Secretary shall make payment for dentures and associated professional services as a bundled payment as determined by the Secretary. In establishing such bundled payment, the Secretary shall consider the national median fee for the service for the year determined under clause
(ii)or
(iii)and the rate determined for such dentures under the Federal Supply Schedule of the General Services Administration, as published by such Administration in 2021, updated to the year involved using the applicable percent increase for the year determined under clause (ii)(II), as reduced by the productivity adjustment under clause (ii)(III), and shall ensure that the payment component for dentures under such bundled payment does not exceed the maximum rate determined for such dentures under the Federal Supply Schedule, as so published and updated to the year involved. The Secretary shall update payment amounts determined under the fee schedule from year to year beginning in 2029 (or 2028, in the case of dentures) by increasing such amounts from the prior year by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II). The Secretary shall, to the extent the Secretary determines to be necessary and subject to subclause (II), adjust the amounts determined under the fee schedule established under this paragraph for 2029 (or 2028, in the case of dentures) and subsequent years to take into account changes in dental practice, coding changes, new data on work, practice, or malpractice expenses, or the addition of new procedures. The adjustments under subclause
(I)for a year shall not cause the amount of expenditures under this part for the year to differ by more than $20,000,000 from the amount of expenditures under this part that would have been made if such adjustments had not been made. With respect to dental and oral health services that are preventive and screening services described in paragraph (1)(A) of section 1861(ooo)— payment shall be made under this part for— not more than 2 oral exams in a year; not more than 2 dental cleanings in a year; not more than 1 fluoride treatment in a year; and not more than 1 full-mouth series of x-rays as part of a preventive and screening oral exam every 3 years; and in the case of preventive and screening services not described in subparagraph (A), payment shall be made under this part only at such frequencies determined appropriate by the Secretary. In the case of dental and oral health services furnished by a doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)) or an oral health professional (as defined in section 1861(ooo)(3)) who predominantly furnishes such services under this part in an area that is designated by the Secretary (under section 332(a)(1)(A) of the Public Health Service Act) as a health professional shortage area, in addition to the amount of payment that would otherwise be made for such services under this subsection, there also shall be paid an amount equal to 10 percent of the payment amount for the service under this subsection for such doctor or professional. The provisions of section 1848(g) shall apply to a nonparticipating doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)) who does not accept payment on an assignment-related basis for dental and oral health services furnished with respect to an individual enrolled under this part in the same manner as such provisions apply with respect to a physician's service. The Secretary shall designate 1 or more (not to exceed 4) medicare administrative contractors under section 1874A to establish coverage policies and establish such policies and process claims for payment for dental and oral health services, as determined appropriate by the Secretary. . 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: With respect to 2029 and each subsequent year, an oral health professional (as defined in section 1861(ooo)(3)). . Section 1862(a) of the Social Security Act ( 42 U.S.C. 1395y(a) ) is amended— in paragraph (1)— in subparagraph (O), by striking and at the end; in subparagraph (P), by striking the semicolon at the end and inserting , and ; and by adding at the end the following new subparagraph: in the case of dental and oral health services (as defined in section 1861(ooo)) for which a limitation is applicable under section 1834(bb)(3), which are furnished more frequently than is provided under such section; ; and in paragraph (12), by inserting before the semicolon at the end the following: and except that payment shall be made under part B for dental and oral health services that are covered under section 1861(s)(2)(LL) . Section 1821(b)(5)(A) of the Social Security Act ( 42 U.S.C. 1395i–5(b)(5)(A) ) is amended— in clause (ii), by striking or at the end; in clause (iii), by striking the period and inserting , or ; and by adding at the end the following new clause: consisting of dental and oral health services (as defined in subsection
(ooo)of section 1861) that are payable under part B as a result of the amendments made by the Medicare Dental, Hearing, and Vision Expansion Act of 2026. . Section 1861(aa) of the Social Security Act ( 42 U.S.C. 1395x(aa) ), is amended— in paragraph (1)— in subparagraph (C), by striking and at the end; in subparagraph (D), by inserting and after the comma at the end; and by inserting after subparagraph
(D)the following new subparagraph: dental and oral health services (as defined in subsection (ooo)) 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 subsection (ooo)(3)) who is employed by or working under contract with a rural health clinic if such rural health clinic furnishes such services, ; and in paragraph (3)(A), by striking
(D)and inserting
(E). Section 1833 of the Social Security Act ( 42 U.S.C. 1395l ) is amended— in subsection (a)(3)(A), by inserting (which shall, in the case of dental and oral health services (as defined in section 1861(ooo))), in lieu of any limits on reasonable costs otherwise applicable, be based on the rates payable for such services under the payment basis determined under section 1848 until such time as the Secretary determines sufficient data has been collected to otherwise apply such limits (or January 1, 2031, if no such determination has been made as of such date)) after may prescribe in regulations ; and by adding at the end the following new subsection: Payments for rural health clinic services other than dental and oral health services (as defined in section 1861(ooo)) under the methodology for all-inclusive rates (established by the Secretary) under subsection (a)(3) shall not take into account the costs of such services while rates for such services are based on rates payable for such services under the payment basis established under section 1848. . Section 1834(o) of the Social Security Act ( 42 U.S.C. 1395m(o) ) is amended by adding at the end the following new paragraph: The Secretary shall, in establishing payment rates for dental and oral health services (as defined in section 1861(ooo)) that are federally qualified health center services under the prospective payment system established under this subsection, in lieu of the rates otherwise applicable under such system, base such rates on rates payable for such services under the payment basis established under section 1848 until such time as the Secretary determines sufficient data has been collected to otherwise establish rates for such services under such system (or January 1, 2031, if no such determination has been made as of such date). Payments for federally qualified health center services other than such dental and oral health services under such system shall not take into account the costs of such services while rates for such services are based on rates payable for such services under the payment basis established under section 1848. . In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2026, out of any money in the Treasury not otherwise appropriated, $900,000,000, to remain available until expended, for purposes of implementing the amendments made by this section during the period beginning on January 1, 2026, and ending on September 30, 2035.
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- 42 USC 1395i–5(b)(5)(A)
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Sec. 402
Coverage of dental and oral health care
Cite42 USC 1395i–5(b)(5)(A)
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