What This Bill Does
This bill aims to improve dental care access for people on Medicaid by reducing barriers that prevent dentists from participating in the program. The bill requires states to simplify how they enroll dentists and define which dental services Medicaid will cover. It also sets rules for how states must audit dental claims fairly.
Who It Affects
States with Medicaid programs, licensed dentists who want to provide services to Medicaid patients, people enrolled in Medicaid who need dental care, and Medicaid managed care plan sponsors.
Key Provisions
• States must remove administrative barriers that make it hard for dentists to participate in Medicaid, including improving eligibility verification processes, letting dentists participate in Medicaid without joining other plans, simplifying how dentists submit claims, and assigning one plan administrator to oversee the dental program (Sec. 2).
• Within one year of the law taking effect, each state Medicaid director must choose an electronic system that reduces paperwork for dentists and gives dentists a decision on whether they can participate within 90 days of applying (Sec. 3).
• States must conduct a study within three years to check whether more dentists are participating in Medicaid after these changes (Sec. 2).
• When states audit dental claims, they must use licensed dentists to review the work and follow established practice guidelines and standards of care (Sec. 3).
• States must allow dentists to resubmit claims that were denied due to unclear documentation, clerical errors, or new interpretations of which services are covered (Sec. 3).
What Changes
Medicaid programs will be required to reduce enrollment barriers for dentists, establish faster credentialing timelines, use fair audit standards that follow dental professional guidelines, and allow resubmission of certain denied claims. Dental and oral health services are now defined in Medicaid law to include dentures, implants, disease prevention, and emergency oral care.
Important Definitions
• Dental and oral health services: dentures and denture services, implants and implant services, and services that prevent oral disease, promote oral health, restore oral structures, reduce oral pain, and treat emergency oral conditions (Sec. 3).
• Integrated data collection system: an electronic system a state uses to enroll, screen, and credential dentists in its Medicaid program (Sec. 3).
I
118TH CONGRESS
1ST SESSION H. R. 1422
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.
IN THE HOUSE OF REPRESENTATIVES
MARCH 7, 2023
Mr. SIMPSON introduced the following bill; which was referred to the
Committee on Energy and Commerce
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.
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE.
3
This Act may be cited as the ‘‘Strengthening Med-
4
icaid Incentives for Licensees Enrolled in Dental Act’’ or
5
the ‘‘SMILED Act’’.
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SEC. 2. SUPPORT FOR ENSURING INDIVIDUALS ENROLLED
1
IN MEDICAID HAVE DENTAL SERVICES AC-
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CESS EQUAL TO THE POPULATION OF THE
3
STATE.
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Section 1903 of the Social Security Act (42 U.S.C.
5
1396b) is amended by adding at the end the following new
6
subsection:
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‘‘(cc) EQUAL ACCESS
TO ORAL HEALTH CARE
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PLAN.—
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‘‘(1) PROVIDER
PARTICIPATION
AND
ACCESS
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REQUIREMENTS.—Not later than 1 year after the
11
date of enactment of this paragraph, a State shall
12
provide the Secretary with assurances that adminis-
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trative barriers to the participation of licensed den-
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tists under this title will be addressed, by—
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‘‘(A) improving eligibility verification;
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‘‘(B) ensuring that any such dentist may
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participate in a publicly funded plan without
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also having to participate in any other plan;
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‘‘(C) simplifying claims forms processing;
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and
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‘‘(D) assigning a single plan administrator
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for the dental program.
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‘‘(2) STUDY ON DENTIST PARTICIPATION.—Not
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later than 3 years after the date on which the assur-
25
ance under paragraph (1) is submitted, each State
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shall conduct a study to determine whether the par-
1
ticipation of licensed dentists have increased fol-
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lowing the assurance provided under paragraph
3
(1).’’.
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SEC. 3. DENTAL AND ORAL HEALTH SERVICES DEFINED;
5
AUDIT REQUIREMENT.
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(a) DENTAL
AND ORAL HEALTH SERVICES DE-
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FINED.—Section 1905 of the Social Security Act (42
8
U.S.C. 1396d) is amended—
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(1) in subsection (a)(10), by inserting ‘‘and
10
dental and oral health services (as defined in sub-
11
section (jj))’’ after ‘‘dental services’’; and
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(2) by adding at the end the following new sub-
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section:
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‘‘(jj) DENTAL AND ORAL HEALTH SERVICES.—
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‘‘(1) IN GENERAL.—For purposes of subsection
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(a)(10), the term ‘dental and oral health services’
17
means dentures and denture services, implants and
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implant services, and services necessary to prevent
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oral disease and promote oral health, restore oral
20
structures to health and function, reduce oral pain,
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and treat emergency oral conditions, that are fur-
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nished by a provider who—
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‘‘(A) is legally authorized to furnish such
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items and services under State law (or the
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State regulatory mechanism provided by State
1
law);
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‘‘(B) is initially credentialed by a State
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Medicaid program (or the designated entity of
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such program) through an integrated data col-
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lection system, as described in paragraph (3);
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and
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‘‘(C) is, as applicable, re-credentialed
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through such integrated data collection system
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by a State Medicaid program (or the designated
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entity of such program).
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‘‘(2) SELECTION
OF
DATA
COLLECTION
SYS-
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TEM.—Not later than one year after the date of en-
13
actment of this subsection, the State Medicaid Di-
14
rector shall select an integrated data collection sys-
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tem (as defined in paragraph (3) that—
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‘‘(A) minimizes provider paperwork bur-
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den; and
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‘‘(B) communicates final credentialing de-
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cisions to providers within 90 days of receipt of
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a completed application.
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‘‘(3) INTEGRATED DATA COLLECTION SYSTEM
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DEFINED.—For purposes of this subsection, the
23
term ‘integrated data collection system’ means an
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electronic system maintained by a State and used
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for
purposes
of
enrolling,
screening,
and
1
credentialing dentists under a State Medicaid pro-
2
gram.’’.
3
(b) DENTAL AND ORAL HEALTH SERVICES AUDIT
4
REQUIREMENT.—Not later than 90 days after the date
5
of enactment of this Act, a State Medicaid program, in-
6
cluding a program offered by a sponsor of a Medicaid
7
managed care plan, that offers dental and oral health serv-
8
ices audits a claim for such dental and oral health services
9
shall—
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(1) utilize a licensed health care professional
11
from the dental specialty area of practice being au-
12
dited to establish relevant audit methodology con-
13
sistent with—
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(A) established practice guidelines, stand-
15
ards of care, and State-issued dental Medicaid
16
provider handbooks; and
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(B) established clinical practice guidelines
18
and acceptable standards of care established by
19
the dental professional or specialty organiza-
20
tions responsible for setting such standards of
21
care;
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(2) develop and implement, in consultation with
23
the Centers for Medicare & Medicaid Services, a pro-
24
cedure in which an improper payment identified by
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an audit may be resubmitted as a claims adjust-
1
ment, including the resubmission of—
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(A) claims denied as a result of an inter-
3
pretation of scope of services not previously
4
held by the Centers for Medicare & Medicaid
5
Services;
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(B) documentation when the document
7
provided is incomplete, illegible, or unclear; and
8
(C) documentation when clerical errors re-
9
sulted in a denial of claims for services actually
10
provided; and
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(3) disallow the difference between the payment
12
for the service that was provided and the payment
13
for the service that should have been provided if a
14
service was provided and sufficiently documented,
15
but denied because it was determined that a dif-
16
ferent service should have been billed.
17
Æ
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