Sponsors (5)
Adds comprehensive dental/oral health, vision, and hearing/audiology benefits to Medicare, defines covered services (examples: preventive and restorative dental care, eye exams and corrective lenses, audiology care and hearing aids), and phases in Medicare payment shares over several years until the federal share reaches 80%. The Secretary may impose frequency limits, prior authorization, or modify coverage consistent with U.S. Preventive Services Task Force guidance; hearing aids are treated as durable medical equipment with replacement limits. The bill also raises the federal Medicaid matching rate (FMAP) to 90% for those same dental, vision, and hearing services for qualifying adult services provided beginning on the statutory effective date, with certain pediatric exclusions.
Adds dental and oral health services to the list of items and services covered under the referenced part of the Social Security Act by inserting a new subparagraph (KK) to section 1861(s)(2) authorizing coverage for 'dental and oral health services (as defined in subsection (nnn)).'
Adds a new subsection (nnn) to section 1861 defining 'dental and oral health services' to include: (1) routine dental cleanings and exams; (2) basic dental services such as fillings and crowns; (3) major dental services such as root canals and extractions; (4) emergency dental care; and (5) other necessary services related to dental or oral health as defined by the Secretary.
Establishes payment rules for dental and oral health services by adding new subsection (aa) to section 1834: payment is the 'applicable percent' of the lesser of the actual charge or the amount determined under the payment basis in section 1848 (i.e., percent of the lesser of charge or usual payment basis).
Sets the schedule for the 'applicable percent' used to calculate payment: (A) first year (beginning at least 6 months after enactment) = 0%; (B) each year after the first through the seventh year the percent increases by 10 percentage points over the previous year; and (C) starting in the eighth year and each year after, the applicable percent is 80%.
Limits frequency for routine services: payment allowed for no more than two routine dental cleanings in a 12-month period, and no more than two routine exams in a 12-month period.
Who is affected and how:
Medicare beneficiaries (especially seniors and younger people with Medicare coverage): Gain entitlement to a range of dental, vision, and hearing services that were largely uncovered by traditional Medicare; however, Medicare’s initial payment share is phased in (starting at 0% the first year for some benefits), so cost-sharing and actual reimbursement to providers will change over time. Over the eight‑year phase-in beneficiaries should face lower out‑of‑pocket costs as Medicare’s share rises toward 80%.
People who are deaf or hard of hearing / people with vision or dental care needs: Will potentially have better access to diagnostic, rehabilitative, and device coverage (hearing aids, eyeglasses, dentures) when services are in force and Medicare begins paying a larger share. Access timing and device replacement rules will be shaped by administrative limits and prior authorization requirements.
Health care providers (dentists, dental clinics, optometrists/ophthalmologists, audiologists, hearing aid providers): Could see increased patient volume from Medicare enrollees but reimbursement rates and administrative burden will vary during the phase-in; initial low Medicare payment shares may discourage some providers until rates improve. New billing, prior authorization, and DME rules (for hearing aids) will require operational changes.
State governments and Medicaid programs: Receive a financial incentive (90% FMAP) for furnishing these services, lowering state share for covered adult services starting on the effective date; states still must decide scope of coverage, provider networks, and how to incorporate the benefit into their programs. The FMAP exclusion for certain children means states may still bear normal matching costs for pediatric services in specified eligibility categories.
Federal budget and taxpayers: The federal government will incur increased spending, first through Medicare as the program’s payment share phases in to 80%, and also through the higher Medicaid matching rate (90%) which increases federal outlays relative to current law for covered services. The legislation delegates substantial discretion to HHS for limits and utilization controls, which will affect cost trajectories.
Program administration and access: The Secretary’s authority to set frequency limits, prior authorization, and USPSTF‑aligned modifications means access may be constrained in practice to control utilization and costs; rulemaking will determine clinical criteria, billing rules, and operational timelines, affecting speed and equity of access.
Overall, the bill significantly expands entitlement-style benefits in Medicare for services many beneficiaries currently pay for out-of-pocket or receive through supplemental coverage, while offering states a large federal match to encourage Medicaid provision; implementation choices will strongly influence real-world access and fiscal outcomes.
Read twice and referred to the Committee on Finance.
Last progress June 12, 2025 (8 months ago)
Introduced on June 12, 2025 by Angela Deneece Alsobrooks