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H.R. 5396 (114th): Medicare Dental, Vision, and Hearing Benefit Act of 2016

The text of the bill below is as of Jun 7, 2016 (Introduced).

I

114th CONGRESS

2d Session

H. R. 5396

IN THE HOUSE OF REPRESENTATIVES

June 7, 2016

(for himself, Mr. Conyers, Mr. Cummings, Mrs. Dingell, Mr. Grayson, and Ms. Schakowsky) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To amend title XVIII of the Social Security Act to provide for coverage of dental, vision, and hearing care under the Medicare program.

1.

Short title

This Act may be cited as the Medicare Dental, Vision, and Hearing Benefit Act of 2016.

2.

Dental and oral health care

(a)

Coverage

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—

(1)

in subparagraph (EE), by striking and after the semicolon at the end;

(2)

in subparagraph (FF), by adding and after the semicolon at the end; and

(3)

by adding at the end the following new subparagraph:

(GG)

dental and oral health services (as defined in subsection (iii));

.

(b)

Dental and oral health services defined

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

(iii)

Dental and oral health services

The term dental and oral health services means—

(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).

.

(c)

Payment; coinsurance; and limitations

(1)

In general

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—

(A)

by striking and before (AA); and

(B)

by inserting before the semicolon at the end the following: , and (BB) with respect to dental and oral health services (as defined in section 1861(iii)), the amount paid shall be the payment amount specified under section 1834(t).

(2)

Payment and limits specified

Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

(t)

Payment and limits for dental and oral health services

(1)

In general

The payment amount under this part for dental and oral health services (as defined in section 1861(iii)) shall be, subject to paragraph (3), the applicable percent (specified in paragraph (2)) of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848.

(2)

Applicable percent

For purposes of paragraph (1), the applicable percent specified in this paragraph is—

(A)

for the first year beginning at least 6 months after the date of the enactment of this subsection, 0 percent;

(B)

for the year following the year specified in subparagraph (A) and each subsequent year through the seventh year following the year specified in subparagraph (A), the applicable percent specified in this paragraph for the previous year increased by 10 percentage points; and

(C)

for the eighth year following the year specified in subparagraph (A) and each subsequent year, 80 percent.

(3)

Limitations and Secretarial authority

(A)

Frequency

With respect to dental and oral health services that are—

(i)

routine dental cleanings, payment may be made under this part for only two such cleanings during a 12-month period; and

(ii)

routine exams, payment may be made under this part for only two such exams during a 12-month period.

(B)

Secretarial authority

(i)

Authority to apply additional limitations

The Secretary may apply such other reasonable limitations on the extent to which dental and oral services are covered under this part, including through application of a prior authorization requirement.

(ii)

Authority to modify coverage

Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of dental and oral health services to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force.

.

(d)

Payment under physician fee schedule

Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(GG), before (3).

(e)

Dentures

(1)

In general

Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)) is amended—

(A)

by striking (other than dental) and inserting (including dentures); and

(B)

by striking internal body.

(2)

Special payment rules

Section 1834(a) of the Social Security Act (42 U.S.C. 1395m(a)) is amended by adding at the end the following new paragraph:

(23)

Payment and limits for dentures

(A)

In general

The payment amount under this part for dentures shall be, subject to subparagraph (C), the applicable percent (specified in subparagraph (B)) of the amount otherwise payable for such dentures under this section.

(B)

Applicable percent

For purposes of subparagraph (A), the applicable percent specified in this subparagraph is—

(i)

for the first year beginning at least 6 months after the date of the enactment of this paragraph, 0 percent;

(ii)

for the year following the year specified in clause (i) and each subsequent year through the seventh year following the year specified in clause (i), the applicable percent specified in this subparagraph for the previous year increased by 10 percentage points; and

(iii)

for the eighth year following the year specified in clause (i) and each subsequent year, 80 percent.

(C)

Limitations and Secretarial authority

(i)

In general

Payment may be made under this part for an individual for—

(I)

not more than one full upper and one full lower denture once every five years; and

(II)

not more than one partial upper denture and one partial lower denture once every five years.

(ii)

Secretarial authority

(I)

Authority to apply additional limitations

The Secretary may apply such other reasonable limitations on the extent to which dentures are covered under this part, including through application of a prior authorization requirement.

(II)

Authority to modify coverage

Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of dentures to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force.

.

(f)

Repeal of ground for exclusion

Section 1862(a) of the Social Security Act (42 U.S.C. 1395y) is amended by striking paragraph (12).

(g)

Effective date

The amendments made by this section shall apply to services furnished on or after January 1 of the first year beginning at least six months after the date of the enactment of this Act.

3.

Vision care

(a)

Coverage

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 2, is further amended—

(1)

in subparagraph (FF), by striking and after the semicolon at the end;

(2)

in subparagraph (GG), by adding and after the semicolon at the end; and

(3)

by adding at the end the following new subparagraph:

(HH)

vision services (as defined in subsection (jjj));

.

(b)

Vision services defined

Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 2, is further amended by adding at the end the following new subsection:

(jjj)

Vision services

The term vision services means—

(1)

routine eye examinations and procedures performed (during the course of any eye examination) to determine the refractive state of the eyes; and

(2)

other necessary services related to eye and vision health (as defined by the Secretary).

.

(c)

Payment; coinsurance; and limitations

(1)

In general

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 2, is further amended—

(A)

by striking and before (BB); and

(B)

by inserting before the semicolon at the end the following: , and (CC) with respect to vision services (as defined in section 1861(jjj)), the amount paid shall be the payment amount specified under section 1834(u).

(2)

Payment and limits specified

Section 1834 of the Social Security Act (42 U.S.C. 1395m), as amended by section 2, is further amended by adding at the end the following new subsection:

(u)

Payment and limits for vision services

(1)

In general

The payment amount under this part for vision services (as defined in section 1861(jjj)) shall be, subject to paragraph (3), the applicable percent (specified in paragraph (2)) of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848.

(2)

Applicable percent

For purposes of paragraph (1), the applicable percent specified in this paragraph is—

(A)

for the first year beginning at least 6 months after the date of the enactment of this subsection, 0 percent;

(B)

for the year following the year specified in subparagraph (A) and each subsequent year through the seventh year following the year specified in subparagraph (A), the applicable percent specified in this paragraph for the previous year increased by 10 percentage points; and

(C)

for the eighth year following the year specified in subparagraph (A) and each subsequent year, 80 percent.

(3)

Limitations and Secretarial authority

(A)

Frequency

With respect to routine eye exams, payment may be made under this part for only one such exam during a 12-month period.

(B)

Secretarial authority

(i)

Authority to apply additional limitations

The Secretary may apply other reasonable limitations on the extent to which vision services are covered under this part, including through application of a prior authorization requirement.

(ii)

Authority to modify coverage

Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of vision services to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force.

.

(d)

Payment under physician fee schedule

Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(HH), after (2)(GG), (as added by section 2).

(e)

Special payment rules for eyeglasses, contact lenses, and low vision devices

Section 1834(a) of the Social Security Act (42 U.S.C. 1395m(a)), as amended by section 2, is further amended by adding at the end the following:

(24)

Payment and limits for eyeglasses and contact lenses

(A)

In general

The payment amount under this part for eyeglass lenses, eyeglass frames, and contact lenses shall be, subject to subparagraph (C), the applicable percent (specified in subparagraph (B)) of the amount otherwise payable for such eyeglass lenses, eyeglass frames, and contact lenses, respectively, under this section.

(B)

Applicable percent

For purposes of subparagraph (A), the applicable percent specified in this subparagraph is—

(i)

for the first year beginning at least 6 months after the date of the enactment of this paragraph, 0 percent;

(ii)

for the year following the year specified in clause (i) and each subsequent year through the seventh year following the year specified in clause (i), the applicable percent specified in this subparagraph for the previous year increased by 10 percentage points; and

(iii)

for the eighth year following the year specified in clause (i) and each subsequent year, 80 percent.

(C)

Limitations and Secretarial authority

(i)

In general

Payment may be made under this part (other than for eyewear described in section 1861(s)(8)) for an individual for—

(I)

not more than one pair of eyeglass lenses during any 12-month period;

(II)

not more than one set of eyeglass frames during any 24-month period; and

(III)

contact lenses, only to the extent that the sum of such payments for contact lenses does not exceed a limitation of $200 during any 24-month period beginning during the first year beginning at least six months after the date of the enactment of this paragraph (or, beginning during a subsequent year, such limitation for a 24-month period beginning in the previous year increase by an appropriate inflation adjustment specified by the Secretary).

(ii)

Secretarial authority

(I)

Authority to apply additional limitations

The Secretary may apply such other reasonable limitations on the extent to which eyeglass lenses, eyeglass frames, and contact lenses are covered under this part, including through application of a prior authorization requirement.

(II)

Authority to modify coverage

Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of eyeglass lenses, eyeglass frames, and contact lenses to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force.

(25)

Payment and limits for low vision devices

(A)

In general

The payment amount under this part for low vision devices shall be, subject to subparagraph (C), the applicable percent (specified in subparagraph (B)) of the amount otherwise payable for low vision devices under this section.

(B)

Applicable percent

For purposes of subparagraph (A), the applicable percent specified in this subparagraph is—

(i)

for the first year beginning at least 6 months after the date of the enactment of this paragraph, 0 percent;

(ii)

for the year following the year specified in clause (i) and each subsequent year through the seventh year following the year specified in clause (i), the applicable percent specified in this subparagraph for the previous year increased by 10 percentage points; and

(iii)

for the eighth year following the year specified in clause (i) and each subsequent year, 80 percent.

(C)

Secretarial authority

(i)

Authority to apply limitations

The Secretary may apply reasonable limitations on the extent to which low vision devices are covered under this part, including through application of a prior authorization requirement.

(ii)

Authority to modify coverage

Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of low vision devices to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force.

(D)

Low vision device defined

In this paragraph, the term low vision device means a device, prescribed by a physician, that magnifies, enhances, or otherwise augments or interprets visual images irrespective of the size, form, or technological features of such device and does not include ordinary eyeglasses or contact lenses. In the previous sentence, the term ordinary eyeglasses or contact lenses means lenses that are intended to fully correct visual acuity or fully eliminate refractive error.

.

(f)

Definition of durable medical equipment To include eyeglasses, contact lenses, and low vision devices

Section 1861(n) of the Social Security Act (42 U.S.C. 1395x(n)) is amended—

(1)

by striking and before eye tracking and inserting a comma; and

(2)

by inserting , and eyeglass lenses, low vision devices (as defined in section 1834(a)(25)), eyeglass frames, and contact lenses before ; except.

(g)

Repeal of ground for exclusion

Section 1862(a)(7) of the Social Security Act (42 U.S.C. 1395y(a)(7)) is amended by striking , eyeglasses (other than eyewear described in section 1861(s)(8)) or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine the refractive state of the eyes.

(h)

Effective date

The amendments made by this section shall apply to services furnished on or after January 1 of the first year beginning at least six months after the date of the enactment of this Act.

4.

Hearing care

(a)

Coverage

(1)

In general

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by sections 2 and 3, is further amended—

(A)

in subparagraph (GG), by striking and at the end;

(B)

in subparagraph (HH), by inserting and at the end; and

(C)

by adding at the end the following new subparagraph:

(II)

audiology services (as defined in subsection (ll)(3)) and hearing services (as defined in subsection (ll)(5));

.

(2)

Hearing services defined

Section 1861(ll) of the Social Security Act (42 U.S.C. 1395x(ll)) is amended—

(A)

in the subsection heading, by inserting ; Hearing Services after Audiology Services; and

(B)

by adding at the end the following new paragraph:

(5)

The term hearing services means—

(A)

routine hearing exams and exams for hearing aids; and

(B)

other necessary services related to hearing health (as defined by the Secretary).

.

(b)

Payment; coinsurance; and limitations

(1)

In general

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by sections 2 and 3, is further amended—

(A)

by striking and before (CC); and

(B)

by inserting before the semicolon at the end the following: , and (DD) with respect to audiology services (as defined in section 1861(ll)(3)) and hearing services (as defined in section 1861(ll)(5)), the amount paid shall be the payment amount specified under section 1834(v).

(2)

Payment and limits specified

Section 1834 of the Social Security Act (42 U.S.C. 1395m), as amended by sections 2 and 3, is further amended by adding at the end the following new subsection:

(v)

Payment and limits for hearing services

(1)

In general

The payment amount under this part for audiology services (as defined in section 1861(ll)(3)) and hearing services (as defined in section 1861(ll)(5)), shall be, subject to paragraph (3), the applicable percent (specified in paragraph (2)) of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848.

(2)

Applicable percent

For purposes of paragraph (1), the applicable percent specified in this paragraph is—

(A)

for the first year beginning at least 6 months after the date of the enactment of this subsection, 0 percent;

(B)

for the year following the year specified in subparagraph (A) and each subsequent year through the seventh year following the year specified in subparagraph (A), the applicable percent specified in this paragraph for the previous year increased by 10 percentage points; and

(C)

for the eighth year following the year specified in subparagraph (A) and each subsequent year, 80 percent.

(3)

Secretarial authority

(A)

Authority to apply limitations

The Secretary may apply reasonable limitations on the extent to which audiology services and hearing services are covered under this part, including through application of a prior authorization requirement.

(B)

Authority to modify coverage

Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of audiology services and hearing services to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force.

.

(c)

Payment under the physician fee schedule

Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)), as amended by section 2(d), is further amended by inserting (2)(II), before (3).

(d)

Hearing aids

(1)

Repeal of ground for exclusion

Section 1862(a)(7) of the Social Security Act (42 U.S.C. 1395y(a)(7)), as amended by section 3(g), is further amended by striking , hearing aids or examinations therefor,.

(2)

Definition of durable medical equipment to include hearing aids

Section 1861(n) of the Social Security Act (42 U.S.C. 1395x(n)), as amended by section 3, is further amended by inserting hearing aids, before and eyeglass lenses.

(3)

Special payment rules for hearing aids

Section 1834(a) of the Social Security Act (42 U.S.C. 1395m(a)), as amended by sections 2 and 3, is further amended by adding at the end the following new paragraph:

(26)

Payment and limits for hearing aids

(A)

In general

The payment amount under this part for hearing aids shall be, subject to subparagraph (C), the applicable percent (specified in subparagraph (B)) of the amount otherwise payable for hearing aids under this section.

(B)

Applicable percent

For purposes of subparagraph (A), the applicable percent specified in this subparagraph is—

(i)

for the first year beginning at least 6 months after the date of the enactment of this paragraph, 0 percent;

(ii)

for the year following the year specified in clause (i) and each subsequent year through the seventh year following the year specified in clause (i), the applicable percent specified in this subparagraph for the previous year increased by 10 percentage points; and

(iii)

for the eighth year following the year specified in clause (i) and each subsequent year, 80 percent.

(C)

Limitations and Secretarial authority

(i)

In general

Payment may be made under this part for an individual for not more than one hearing aid per ear during a 48-month period.

(ii)

Secretarial authority

(I)

Authority to apply additional limitations

The Secretary may apply additional limitations on the extent to which hearing aids are covered under this part, including through application of a prior authorization requirement and through application of criteria for a minimum level of hearing loss for coverage of an initial or replacement hearing aid.

(II)

Authority to modify coverage

Notwithstanding any other provision of this title, if the Secretary determines appropriate, the Secretary may modify the coverage under this part of hearing aids to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force.

.

(e)

Effective date

The amendments made by this section shall apply to services furnished on or after January 1 of the first year beginning at least six months after the date of the enactment of this Act.