H.R. 42 | Medicare and Medicaid Dental, Vision, and Hearing Benefit Act of 2025

[Brink]

119th CONGRESS
1st Session
H.R. 42

To amend titles XVIII and XIX of the Social Security Act to provide for coverage of dental and oral health services, vision services, and hearing services under the Medicare and Medicaid programs.

IN THE SENATE OF THE UNITED STATES
Q1, 2025
Ms. O'Hare (for herself and others with thanks to Mr. Casey) introduced the following bill; 

A BILL
To amend titles XVIII and XIX of the Social Security Act to provide for coverage of dental and oral health services, vision services, and hearing services under the Medicare and Medicaid programs.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. Short title.

This Act may be cited as the “Medicare and Medicaid Dental, Vision, and Hearing Benefit Act of 2025”.

SEC. 2. Dental and oral health services under Medicare.

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

(1) in subparagraph (II), by striking “and” after the semicolon at the end;

(2) in subparagraph (JJ), by adding “and” after the semicolon at the end; and

(3) by adding at the end the following new subparagraph:

“(KK) dental and oral health services (as defined in subsection (nnn));”.

(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:

“Dental And Oral Health Services
“(nnn) 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 “(HH)”; and

(B) 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(nnn)), the amount paid shall be the payment amount specified under section 1834(aa)”.

(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:

“(aa) 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(nnn)) 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)(KK),” 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.

SEC. 3. Vision services under Medicare.

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

(1) in subparagraph (JJ), by striking “and” after the semicolon at the end;

(2) in subparagraph (KK), by adding “and” after the semicolon at the end; and

(3) by adding at the end the following new subparagraph:

“(LL) vision services (as defined in subsection (mmm));”.

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

“Vision Services
“(ooo) 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(c)(1), is amended—

(A) by striking “and” before “(II)”; and

(B) by inserting before the semicolon at the end the following: “, and (JJ) with respect to vision services (as defined in section 1861(mmm)), the amount paid shall be the payment amount specified under section 1834(bb)”.

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

“(bb) Payment and limits for vision services.—

“(1) IN GENERAL.—The payment amount under this part for vision services (as defined in section 1861(mmm)) 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)), as amended by section 2(d), is amended by inserting “(2)(LL),” after “(2)(KK),”.

(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(e)(2), is amended by adding at the end the following new paragraphs:

“(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.

SEC. 4. Hearing services under Medicare.

(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(a) and 3(a), is amended—

(A) in subparagraph (KK), by striking “and” after the semicolon at the end;

(B) in subparagraph (LL), by inserting “and” after the semicolon at the end; and

(C) by adding at the end the following new subparagraph:

“(MM) 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(c)(1) and 3(c)91), is amended—

(A) by striking “and” before “(JJ)”; and

(B) by inserting before the semicolon at the end the following: “, and (KK) 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(cc)”.

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

“(cc) 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 sections 2(d) and 3(d), is amended by inserting “(2)(MM),” after “(2)(LL),”.

(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 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(f), is 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(e)(2) and 3(e), is 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.

SEC. 5. Increased FMAP for coverage of dental and oral health services, vision services, and hearing services under Medicaid.

Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—

(1) in subsection (a)—

(A) in paragraph (10), by inserting “, which may include any dental and oral health service (as defined in section 1861(nnn))” after “dental services”;

(B) in paragraph (13)—

(i) in subparagraph (B), by striking “; and” and inserting a semicolon;

(ii) in subparagraph (C), by striking the semicolon and inserting “; and”; and

(iii) by adding at the end the following new subparagraph:

“(D) any service that is a vision service (as defined in section 1861(ooo)) or a hearing service (as defined in section 1861(ll)(5);”;

(2) in subsection (b), by striking “and (ii)” and inserting “(ii), and (jj)”; and

(3) by adding at the end the following new subsection:

“(jj) Increased FMAP for expenditures for dental and oral health services, vision services, and hearing services.—

“(1) IN GENERAL.—Notwithstanding subsection (b), the Federal medical assistance percentage with respect to amounts expended by a State for medical assistance for services described in paragraph (2) shall be equal to 90 percent.

“(2) SERVICES DESCRIBED.—A service described in this paragraph is any service that—

“(A) is furnished on or after January 1 of the first calendar year that begins at least 6 months after the date of the enactment of this subsection;

“(B) is not furnished to an individual who is—

“(i) under the age of 21; and

“(ii) eligible for medical assistance for the services described in subsection (a)(4)(B); and

“(C) is—

“(i) a dental and oral health service (as defined in section 1861(nnn));

“(ii) a vision service (as defined in section 1861(ooo)); or

“(iii) a hearing service (as defined in section 1861(ll)(5)).”.

PES: 

This bill provides for Medicare coverage of dental, vision, and hearing care. Coverage includes (1) routine dental cleanings and exams, basic and major dental services, emergency dental care, and dentures; (2) routine eye exams, eyeglasses, and contact lenses; and (3) routine hearing exams, hearing aids, and exams for hearing aids. With respect to such care, the bill establishes special payment rules, limitations, and coinsurance requirements.

The bill also increases the Medicaid Federal Medical Assistance Percentage (i.e., federal matching rate) for dental, vision, and hearing services.

Edited January 11 by Brink

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The House shall come to order to debate this legislation for a period of 72 hours.

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The House shall vote on if to pass this legislation for 24 hours.

[DMH]

Nay

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The legislation fails 0-433.