II 

113TH CONGRESS 

1ST SESSION S. 1522 

To improve access to oral health care for vulnerable and underserved 

populations. 

IN THE SENATE OF THE UNITED STATES 

SEPTEMBER 18, 2013 

Mr. SANDERS (for himself and Mr. SCHATZ) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To improve access to oral health care for vulnerable and 

underserved populations. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Comprehensive Dental 

5 Reform Act of 2013’’. 

6 SEC. 2. TABLE OF CONTENTS. 

7 The table of contents of this Act is as follows: 

Sec. 1. Short title. 

Sec. 2. Table of contents. 

Sec. 3. Findings. 

TITLE I—MEDICARE AND MEDICAID 

Subtitle A—Medicare 


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Sec. 101. Coverage of dental services under the Medicare program. 

Subtitle B—Medicaid 

Sec. 111. Coverage of dental services under the Medicaid program. 

TITLE II—PUBLIC HEALTH PROGRAMS 

Subtitle A—National Health Service Corps 

Sec. 201. National Health Service Corps. 

Sec. 202. Community based dental residencies. 

Subtitle B—Oral Health Education 

Sec. 211. Authorization of appropriations for oral health education for medical 

providers. 

Sec. 212. Oral health education for other non-health professionals. 

Sec. 213. Dental education. 

Sec. 214. Oral health professional student loans. 

Subtitle C—Other Oral Health Programs 

Sec. 221. Access points. 

Sec. 222. Dental clinics in schools. 

Sec. 223. Emergency room care coordination. 

Sec. 224. Research funding. 

Sec. 225. Mobile and portable dental services. 

Subtitle D—Oral Health Services as an Essential Health Benefit 

Sec. 231. Oral health services as an essential health benefit. 

TITLE III—DEPARTMENT OF VETERANS AFFAIRS AND 

DEPARTMENT OF DEFENSE MATTERS 

Subtitle A—Department of Veterans Affairs Matters 

Sec. 301. Requiring the Secretary of Veterans Affairs to furnish dental care in 

the same manner as any other medical service. 

Sec. 302. Demonstration program on training and employment of alternative 

dental health care providers for dental health care services for 

veterans in rural and other underserved communities. 

Subtitle B—Department of Defense Matters 

Sec. 311. Demonstration program on training and employment of alternative 

dental health care providers for dental health care services for 

members of the Armed Forces and dependents lacking ready 

access to such services. 

TITLE IV—FEDERAL BUREAU OF PRISONS 

Sec. 401. Demonstration program on training and employment of alternative 

dental health care providers for dental health care services for 

prisoners within the custody of the Bureau of Prisons. 

TITLE V—INDIAN HEALTH SERVICE 


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Sec. 501. Demonstration program on training and employment of alternative 

dental health care providers for dental health care services 

under the Indian Health Service. 

TITLE VI—REPORTS TO CONGRESS 

Sec. 601. Evaluation of expansion of coverage for dental services. 

1 SEC. 3. FINDINGS. 

2 Congress makes the following findings: 

3 (1) The United States must establish a nation4 wide and comprehensive approach to address the 

5 lack of access to needed dental care and reduce oral 

6 health disparities. 

7 (2) Since 2000, when the Surgeon General of 

8 the United States called dental disease a ‘‘silent epi9 demic’’, there has been increasing but still insuffi10 cient attention given to addressing oral health 

11 issues. The Healthy People 2020 initiative includes 

12 oral health as a leading health indicator for the first 

13 time in the history of the Healthy People program, 

14 and in 2011, the Institute of Medicine published 2 

15 reports, ‘‘Improving Access to Oral Health Care for 

16 Vulnerable and Underserved Populations’’ and ‘‘Ad17 vancing Oral Health in America’’, that focused on 

18 oral health. 

19 (3) Dental caries, commonly known as cavities, 

20 are the most common chronic disease for children in 

21 the United States. Additionally, 25 percent of AmerVerDate Mar 15 2010 03:58 Sep 19, 2013 Jkt 029200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1522.IS S1522

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1 ican adults who have attained 65 years of age have 

2 lost all of their teeth. 

3 (4) Untreated oral health problems contribute 

4 to an increased risk for serious medical conditions 

5 such as diabetes, hospital-acquired pneumonia, and 

6 poor birth outcomes. 

7 (5) According to a report by the Surgeon Gen8 eral of the United States, students miss more than 

9 51,000,000 hours of school and employed adults lose 

10 more than 164,000,000 hours of work each year due 

11 to dental disease and dental visits. 

12 (6) While the lack of access to oral health serv13 ices is a national problem, those who are most likely 

14 to remain underserved are individuals with low in15 comes, racial and ethnic minorities, pregnant 

16 women, older adults, individuals with special needs, 

17 and individuals living in rural communities. 

18 (7) More than 1 in 4 Americans do not have 

19 dental health insurance which is far greater than the 

20 number of individuals who lack general health insur21 ance. 

22 (8) The Medicare program and the Department 

23 of Veterans Affairs do not provide dental coverage to 

24 the majority of their beneficiaries, and States can 


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1 elect whether to provide dental coverage to adults 

2 under the Medicaid program. 

3 (9) Only 20 percent of practicing dentists in the 

4 United States provide care to individuals enrolled in 

5 Medicaid, and a very small percentage of dentists 

6 devote a substantial part of their practice towards 

7 caring for individuals who are underserved. 

8 (10) The United States spends more than 

9 $100,000,000,000 on dental care and that number 

10 is expected to rise to nearly $170,000,000,000 by 

11 2020. Over $30,000,000,000 dollars was spent out12 of-pocket for dental services in 2008. 

13 (11) The lack of access to oral health services 

14 results in higher health care expenditures. In 2009, 

15 there were over 830,000 visits to emergency rooms 

16 across the United States for preventable dental con17 ditions, which is 16 percent higher than in 2006. 

18 The treatment of dental conditions in hospital emer19 gency rooms in 2010 cost as much as 

20 $2,100,000,000. 


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1 TITLE I—MEDICARE AND 

2 MEDICAID 

3 Subtitle A—Medicare 

4 SEC. 101. COVERAGE OF DENTAL SERVICES UNDER THE 

5 MEDICARE PROGRAM. 

6 (a) COVERAGE.—Section 1861(s)(2) of the Social Se7 curity Act (42 U.S.C. 1395x(s)(2)) is amended— 

8 (1) in subparagraph (EE), by striking ‘‘and’’ 

9 after the semicolon at the end; 

10 (2) in subparagraph (FF), by adding ‘‘and’’ 

11 after the semicolon at the end; and 

12 (3) by adding at the end the following new sub13 paragraph: 

14 ‘‘(GG) dental services (as defined in subsection 

15 (iii));’’. 

16 (b) DENTAL SERVICES DEFINED.—Section 1861(s) 

17 of the Social Security Act (42 U.S.C. 1395x(s)) is amend18 ed by adding at the end the following new subsection: 

19 ‘‘Dental Services 

20 ‘‘(iii)(1) The term ‘dental services’ means oral health 

21 services (as defined by the Secretary) provided by a li22 censed oral health care provider that are necessary to pre23 vent disease and promote oral health, restore oral struc24 tures to health and function, and treat emergency condi25 tions. 


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1 ‘‘(2) For purposes of paragraph (1), such term shall 

2 include mobile and portable oral health services (as de3 fined by the Secretary) that— 

4 ‘‘(A) are provided for the purpose of over5 coming mobility, transportation, and access barriers 

6 for individuals; and 

7 ‘‘(B) satisfy the standards and certification re8 quirements established under section 1902(a)(84)(B) 

9 for the State in which the services are provided.’’. 

10 (c) PAYMENT AND COINSURANCE.—Section 

11 1833(a)(1) of the Social Security Act (42 U.S.C. 

12 1395l(a)(1)) is amended— 

13 (1) by striking ‘‘and’’ before ‘‘(Z)’’; and 

14 (2) by inserting before the semicolon at the end 

15 the following: ‘‘, and (AA) with respect to dental 

16 services (as defined in section 1861(iii)), the amount 

17 paid shall be (i) in the case of such services that are 

18 dental health preventive services described in para19 graph (1)(D) of such section, 100 percent of the 

20 lesser of the actual charge for the services or the 

21 amount determined under the payment basis deter22 mined under section 1848, and (ii) in the case of all 

23 other such services, 80 percent of the lesser of the 

24 actual charge for the services or the amount deterVerDate Mar 15 2010 03:58 Sep 19, 2013 Jkt 029200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1522.IS S1522

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1 mined under the payment basis determined under 

2 section 1848’’. 

3 (d) PAYMENT UNDER PHYSICIAN FEE SCHEDULE.— 

4 Section 1848(j)(3) of the Social Security Act (42 U.S.C. 

5 1395w–4(j)(3)) is amended by inserting ‘‘(2)(GG),’’ after 

6 ‘‘risk assessment),’’. 

7 (e) DENTURES.—Section 1861(s)(8) of the Social Se8 curity Act (42 U.S.C. 1395x(s)(8)) is amended— 

9 (1) by striking ‘‘(other than dental)’’ and in10 serting ‘‘(including dentures)’’; and 

11 (2) by striking ‘‘internal body’’. 

12 (f) REPEAL OF GROUND FOR EXCLUSION.—Section 

13 1862(a) of the Social Security Act (42 U.S.C. 1395y) is 

14 amended by striking paragraph (12). 

15 (g) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to services furnished on or after 

17 January 1, 2014. 

18 Subtitle B—Medicaid 

19 SEC. 111. COVERAGE OF DENTAL SERVICES UNDER THE 

20 MEDICAID PROGRAM. 

21 (a) IN GENERAL.—Section 1905 of the Social Secu22 rity Act (42 U.S.C. 1396d) is amended— 

23 (1) in subsection (a)(10), by adding ‘‘(as de24 scribed in subsection (ee)(1))’’ after ‘‘dental serv25 ices’’; and 


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1 (2) by adding at the end the following: 

2 ‘‘(ee)(1) Subject to paragraphs (2) and (3), for pur3 poses of this title, the term ‘dental services’ means oral 

4 health services (as defined by the Secretary) provided by 

5 a licensed oral health care provider that are necessary to 

6 prevent disease and promote oral health, restore oral 

7 structures to health and function, and treat emergency 

8 conditions. 

9 ‘‘(2) For purposes of paragraph (1), such term shall 

10 include— 

11 ‘‘(A) dentures; and 

12 ‘‘(B) mobile and portable oral health services 

13 (as defined by the Secretary) that— 

14 ‘‘(i) are provided for the purpose of over15 coming mobility, transportation, and access bar16 riers for individuals; and 

17 ‘‘(ii) satisfy the standards and certification 

18 requirements established under section 

19 1902(a)(82)(C) for the State in which the serv20 ices are provided. 

21 ‘‘(3) For purposes of paragraph (1), such term shall 

22 not apply to dental care or services provided to individuals 

23 under the age of 21 under subsection (r)(3).’’. 

24 (b) CONFORMING AMENDMENTS.— 


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1 (1) STATE PLAN REQUIREMENTS.—Section 

2 1902(a) of such Act (42 U.S.C. 1396a(a)) is amend3 ed— 

4 (A) in paragraph (10)(A), in the matter 

5 preceding clause (i), by inserting ‘‘(10),’’ after 

6 ‘‘(5),’’; 

7 (B) in paragraph (80), by striking ‘‘and’’ 

8 at the end; 

9 (C) in paragraph (81), by striking the pe10 riod at the end and inserting ‘‘; and’’; and 

11 (D) by inserting after paragraph (81) the 

12 following: 

13 ‘‘(82) provide for— 

14 ‘‘(A) informing, in writing, all individuals 

15 who have been determined to be eligible for 

16 medical assistance of the availability of dental 

17 services (as defined in section 1905(ee)); 

18 ‘‘(B) conducting targeted outreach to preg19 nant women who have been determined to be el20 igible for medical assistance about the avail21 ability of medical assistance for such dental 

22 services and the importance of receiving dental 

23 care while pregnant; and 

24 ‘‘(C) establishing and maintaining stand25 ards for and certification of mobile and portable 


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1 oral health services (as described in subsections 

2 (r)(3)(C) and (ee)(2)(B) of section 1905).’’. 

3 (2) DEFINITION OF MEDICAL ASSISTANCE.— 

4 Section 1905(a)(12) of such Act (42 U.S.C. 

5 1396d(a)(12)) is amended by striking ‘‘, dentures,’’. 

6 (c) MOBILE AND PORTABLE ORAL HEALTH SERV7 ICES UNDER EPSDT.—Section 1905(r)(3) of the Social 

8 Security Act (42 U.S.C. 1396d(r)(3)) is amended— 

9 (1) in subparagraph (A)(ii), by striking ‘‘; and’’ 

10 and inserting a semicolon; 

11 (2) in subparagraph (B), by striking the period 

12 at the end and inserting ‘‘; and’’; and 

13 (3) by adding at the end the following new sub14 paragraph: 

15 ‘‘(C) which shall include mobile and portable 

16 oral health services (as defined by the Secretary) 

17 that— 

18 ‘‘(i) are provided for the purpose of over19 coming mobility, transportation, or access bar20 riers for children; and 

21 ‘‘(ii) satisfy the standards and certification 

22 requirements established under section 

23 1902(a)(82)(C) for the State in which the serv24 ices are provided.’’. 


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1 (d) INCREASED FEDERAL FUNDING FOR DENTAL

2 SERVICES.— 

3 (1) IN GENERAL.—Section 1905 of the Social 

4 Security Act (42 U.S.C. 1396d), as amended by sub5 section (a), is amended— 

6 (A) in subsection (b), in the first sentence, 

7 by striking ‘‘and (aa)’’ and inserting ‘‘(aa), and 

8 (ff)’’; and 

9 (B) by adding at the end the following new 

10 subsection: 

11 ‘‘(ff) INCREASED FMAP FOR DENTAL SERVICES.— 

12 ‘‘(1) IN GENERAL.—Notwithstanding subsection 

13 (b) and section 1903(a)(7) and subject to the re14 quirements described in paragraphs (3) and (4), 

15 with respect to amounts expended on or after Janu16 ary 1, 2014, for covered dental expenses (as de17 scribed in paragraph (2)), the Federal medical as18 sistance percentage for a State that is one of the 50 

19 States or the District of Columbia for such expenses 

20 shall be equal to the Federal medical assistance per21 centage that would otherwise apply to the State for 

22 the fiscal year, as determined under subsection (b) 

23 or section 1903(a)(7), increased by 15 percentage 

24 points. 


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1 ‘‘(2) COVERED DENTAL EXPENSES.—For pur2 poses of paragraph (1), the term ‘covered dental ex3 penses’ means the amounts expended for medical as4 sistance for dental services (as described in sub5 section (ee)) and amounts expended for the proper 

6 and efficient administration of the provision of such 

7 dental services under the State plan. 

8 ‘‘(3) REQUIREMENTS.—For purposes of para9 graph (1), the Federal medical assistance percentage 

10 applicable to covered dental expenses under this sub11 section shall not apply to a State unless— 

12 ‘‘(A) the State plan for medical assistance 

13 provides payment for dental services (as so de14 fined) furnished by a dental provider at a rate 

15 that is not less than 70 percent of the usual 

16 and customary fee for such services in the 

17 State; and 

18 ‘‘(B) the State satisfies such additional re19 quirements as are established by the Secretary, 

20 which shall include— 

21 ‘‘(i) streamlining of administrative 

22 procedures for purposes of ensuring ade23 quate provider participation and increasing 

24 patient utilization of dental services; and 


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1 ‘‘(ii) the provision of technical assist2 ance to dental providers designed to reduce 

3 the number of missed patient appoint4 ments and reduce other barriers to the de5 livery of oral health services. 

6 ‘‘(4) LIMITATION.—For purposes of amounts 

7 expended for covered dental services, in no case shall 

8 any increase under this subsection result in a Fed9 eral medical assistance percentage that exceeds 100 

10 percent.’’. 

11 (2) CONFORMING AMENDMENT.—Section 

12 1903(a)(7) of the Social Security Act (42 U.S.C. 

13 1396b(a)(7)) is amended by striking ‘‘section 

14 1919(g)(3)(B)’’ and inserting ‘‘sections 1905(ff) and 

15 1919(g)(3)(B)’’. 

16 (e) SECRETARIAL RESPONSIBILITIES.— 

17 (1) TECHNICAL ASSISTANCE AND OUTREACH.— 

18 The Secretary of Health and Human Services, act19 ing through the Administrator of the Centers for 

20 Medicare & Medicaid Services, shall provide tech21 nical assistance to States and conduct outreach to 

22 States for purposes of educating and encouraging 

23 States to utilize and provide payment under each 

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1 ditionally underserved populations in need of such 

2 services. 

3 (2) DATABASE AND ANNUAL REPORT ON DEN4 TAL BENEFITS FOR ADULT MEDICAID ENROLLEES.— 

5 (A) MEDICAID DENTAL BENEFITS DATA6 BASE.—The Secretary of Health and Human 

7 Services, acting through the Administrator of 

8 the Centers for Medicare & Medicaid Services, 

9 shall maintain, as accurately and up-to-date as 

10 possible, a database that contains with respect 

11 to the each State (as defined for purposes of 

12 title XIX of the Social Security Act (42 U.S.C. 

13 1396 et seq.)) information regarding the dental 

14 benefits available for adults enrolled in the 

15 State Medicaid program, including any limits 

16 on such benefits and the amount of reimburse17 ment provided under the State Medicaid pro18 gram for such benefits. The database also shall 

19 include a separate description of the dental ben20 efits, benefit limits, and amount of reimburse21 ment provided under each State Medicaid pro22 gram for pregnant women, if such benefits are 

23 not provided to the woman as part of early and 

24 periodic screening, diagnostic, and treatment 

25 services (as defined in section 1905(r) of the 


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1 Social Security Act (42 U.S.C. 1396d(r))), and 

2 a description of the use of dental services by 

3 children and adults enrolled in the State Med4 icaid program. 

5 (B) ANNUAL REPORT.—The Secretary of 

6 Health and Human Services shall make avail7 able to the public an annual report regarding 

8 the information collected in the database re9 quired under subparagraph (A). Each annual 

10 report under this subparagraph shall include for 

11 each State Medicaid program and with respect 

12 to the most recent year for which data are 

13 available the yearly dental service utilization 

14 rates for children and adults enrolled in the 

15 State Medicaid program. 

16 (f) EFFECTIVE DATE.— 

17 (1) IN GENERAL.—Except as provided in para18 graph (2), the amendments made by this section 

19 shall apply to calendar quarters beginning on or 

20 after January 1, 2014, without regard to whether or 

21 not final regulations to carry out such amendments 

22 have been promulgated by such date. 

23 (2) DELAY PERMITTED FOR STATE PLAN

24 AMENDMENT.—In the case of a State plan for med25 ical assistance under title XIX of the Social Security 


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1 Act which the Secretary of Health and Human Serv2 ices determines requires State legislation (other than 

3 legislation appropriating funds) in order for the plan 

4 to meet the additional requirements imposed by the 

5 amendments made by this section, the State plan 

6 shall not be regarded as failing to comply with the 

7 requirements of such title solely on the basis of its 

8 failure to meet these additional requirements before 

9 the first day of the first calendar quarter beginning 

10 after the close of the first regular session of the 

11 State legislature that begins after the date of enact12 ment of this Act. For purposes of the previous sen13 tence, in the case of a State that has a 2-year legis14 lative session, each year of such session shall be 

15 deemed to be a separate regular session of the State 

16 legislature. 

17 TITLE II—PUBLIC HEALTH 

18 PROGRAMS 

19 Subtitle A—National Health 

20 Service Corps 

21 SEC. 201. NATIONAL HEALTH SERVICE CORPS. 

22 (a) IN GENERAL.—Section 331 of the Public Health 

23 Service Act (42 U.S.C. 254d) is amended— 

24 (1) in subsection (a)(3), by adding at the end 

25 the following: 


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1 ‘‘(F) The term ‘dental therapist’ means, 

2 with respect to a State that licenses such dental 

3 therapists, a mid-level dental practitioner who is 

4 licensed to practice under the law of the State 

5 and who provides preventive and restorative 

6 services directly to the public, commensurate 

7 with the scope of the practice.’’; and 

8 (2) in subsection (b)— 

9 (A) in paragraph (1), by inserting ‘‘, den10 tal therapy,’’ after ‘‘dental’’; and 

11 (B) in paragraph (2), by inserting ‘‘dental 

12 therapists,’’ after ‘‘dentists,’’. 

13 (b) FACILITATION OF EFFECTIVE PROVISION OF

14 CORPS SERVICES.—Section 336(f)(3) of the Public Health 

15 Service Act (42 U.S.C. 254h–1(f)(3)) is amended by in16 serting ‘‘dental therapists’’ after ‘‘midwives,’’. 

17 (c) SCHOLARSHIP PROGRAM AND LOAN REPAYMENT

18 PROGRAM.— 

19 (1) SCHOLARSHIP PROGRAM.—Section 338A of 

20 the Public Health Service Act (42 U.S.C. 254l) is 

21 amended— 

22 (A) in subsection (a)(1), by inserting ‘‘den23 tal therapists,’’ after ‘‘dentists,’’; and 


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1 (B) in subsection (b)(1), by inserting ‘‘in2 cluding dental therapy,’’ after ‘‘or other health 

3 profession,’’. 

4 (2) LOAN REPAYMENT PROGRAM.—Section 

5 338B of the Public Health Service Act (42 U.S.C. 

6 254l–1) is amended— 

7 (A) in subsection (a)(1), by inserting ‘‘den8 tal therapists,’’ after ‘‘dentists,’’; and 

9 (B) in subsection (b)(1)— 

10 (i) in subparagraph (A), by inserting 

11 ‘‘dental therapist,’’ after ‘‘nurse practi12 tioner,’’; 

13 (ii) in subparagraph (B), by inserting 

14 ‘‘dental therapy,’’ after ‘‘mental health,’’; 

15 and 

16 (iii) in subparagraph (C)(ii), by in17 serting ‘‘, including dental therapy,’’ after 

18 ‘‘health profession’’. 

19 (3) AUTHORIZATION OF APPROPRIATIONS.— 

20 Section 338H of the Public Health Service Act (42 

21 U.S.C. 254q) is amended— 

22 (A) in subsection (a), by striking ‘‘this sec23 tion’’ and inserting ‘‘this subpart’’; and 

24 (B) by adding at the end the following: 


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1 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS WITH

2 RESPECT TO ORAL HEALTH PROFESSIONALS.—To carry 

3 out this subpart with respect to dentists, dental therapists, 

4 and dental hygienists, in addition to the amounts author5 ized under subsection (a), there is authorized to be appro6 priated such sums as may be necessary for fiscal years 

7 2014 through 2017, which shall be used to provide an 

8 emergency expansion for scholarships to, and loan repay9 ments on behalf of, such oral health professionals.’’. 

10 SEC. 202. COMMUNITY BASED DENTAL RESIDENCIES. 

11 Section 340H of the Public Health Service Act (42 

12 U.S.C. 256h) is amended by adding at the ending the fol13 lowing: 

14 ‘‘(k) ADDITIONAL FUNDING.—For the purpose of ex15 panding the program under this section, there is author16 ized to be appropriated such sums as may be necessary 

17 for the 5-year period beginning with the fiscal year that 

18 begins not less than 1 year and not more than 2 years 

19 after the date of enactment of the Comprehensive Dental 

20 Reform Act of 2013’’. 


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1 Subtitle B—Oral Health Education 

2 SEC. 211. AUTHORIZATION OF APPROPRIATIONS FOR ORAL 

3 HEALTH EDUCATION FOR MEDICAL PRO4 VIDERS. 

5 Section 747(c) of the Public Health Service Act (42 

6 U.S.C. 293k(c)) is amended by adding at the end the fol7 lowing: 

8 ‘‘(4) ORAL HEALTH EDUCATION.—In addition 

9 to other amounts authorized under this subsection 

10 for purposes of carrying out this section, there is au11 thorized to be appropriated such sums as may be 

12 necessary for fiscal years 2014 through 2017 for the 

13 purpose of educating nondental medical profes14 sionals, including physicians, nurses, nurse practi15 tioners, physician assistants, and pharmacists, about 

16 oral health, including issues such as oral hygiene in17 struction, topical application of fluoride, and oral 

18 health screenings, with the goal of integrating oral 

19 health care into overall health care.’’. 

20 SEC. 212. ORAL HEALTH EDUCATION FOR OTHER NON21 HEALTH PROFESSIONALS. 

22 Subpart I of part C of title VII of the Public Health 

23 Service Act (42 U.S.C. 293k et seq.) is amended by insert24 ing after section 748 the following: 


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1 ‘‘SEC. 748A. ORAL HEALTH EDUCATION FOR OTHER NON2 ORAL HEALTH PROFESSIONALS. 

3 ‘‘(a) IN GENERAL.—The Secretary may make grants 

4 to, or enter into contracts with, an accredited public or 

5 nonprofit private hospital, an educational institution, or 

6 a public or private nonprofit entity which the Secretary 

7 has determined is capable of carrying out such grant or 

8 contract to educate individuals, such as community health 

9 workers, social workers, nutritionists, health educators, 

10 occupational therapists, and psychologists, to promote oral 

11 health education and literacy and to provide support for 

12 behavior change and assistance with care coordination 

13 with respect to oral health. 

14 ‘‘(b) AUTHORIZATION OF APPROPRIATIONS.—To 

15 carry out this section, there is authorized to be appro16 priated such sums as may be necessary for fiscal years 

17 2014 through 2017.’’. 

18 SEC. 213. DENTAL EDUCATION. 

19 Section 748 of the Public Health Service Act (42 

20 U.S.C. 293k–2) is amended— 

21 (1) in subsection (a)(1)(H), by striking ‘‘pedi22 atric training programs’’ and inserting ‘‘pediatric 

23 dental training programs’’; and 

24 (2) in subsection (c)— 

25 (A) by striking the subsection heading and 

26 inserting ‘‘REQUIREMENTS FOR AWARD.—’’; 


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1 (B) by amending the matter preceding 

2 paragraph (1) to read as follows: ‘‘With respect 

3 to training provided for under this section, the 

4 Secretary shall award grants or contracts only 

5 to eligible entities that meet at least 7 of the 

6 following criteria:’’; 

7 (C) in paragraph (2), by striking ‘‘have a 

8 record of training the greatest percentage of 

9 providers, or that have demonstrated significant 

10 improvements in the percentage of providers, 

11 who enter and’’ and inserting ‘‘train significant 

12 numbers of providers who’’; 

13 (D) in paragraph (3)— 

14 (i) by striking ‘‘have a record of train15 ing’’ and inserting ‘‘intent to train’’; and 

16 (ii) by striking the period at the end 

17 and inserting ‘‘and have faculty with expe18 rience in treating underserved popu19 lations.’’; 

20 (E) in paragraph (8), by inserting ‘‘or 

21 have established’’ after ‘‘establish’’; and 

22 (F) by adding at the end the following: 

23 ‘‘(9) Qualified applicants that require not less 

24 than 200 hours of community-based education rota25 tions.’’. 


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1 SEC. 214. ORAL HEALTH PROFESSIONAL STUDENT LOANS. 

2 Part F of title VII of the Public Health Service Act 

3 (42 U.S.C. 295j) is amended by adding at the end the 

4 following: 

5 ‘‘SEC. 799C. ORAL HEALTH PROFESSIONAL STUDENT 

6 LOANS. 

7 ‘‘(a) IN GENERAL.—The Secretary shall establish 

8 and operate a student loan fund for oral health profes9 sional students, including dental hygienists, dental thera10 pists, and dentists. 

11 ‘‘(b) CONTENT.—The Secretary shall establish and 

12 operate the student loan fund program under subsection 

13 (a) in the same manner and subject to the same terms 

14 as the loan fund program established with schools of nurs15 ing under section 835. 

16 ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—To 

17 carry out this section, there are authorized to be appro18 priated such sums as may be necessary for fiscal years 

19 2014 through 2017.’’. 

20 Subtitle C—Other Oral Health 

21 Programs 

22 SEC. 221. ACCESS POINTS. 

23 Subpart X of part D of title III of the Public Health 

24 Service Act (42 U.S.C. 256f et seq.) is amended by adding 

25 at the end the following: 


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1 ‘‘SEC. 340G–2. FUNDING FOR ORAL HEALTH SERVICES. 

2 ‘‘(a) IN GENERAL.—The Secretary, acting through 

3 the Administrator of the Health Resources and Services 

4 Administration, shall establish a program to award grants 

5 to eligible entities to provide oral health services, or to con6 tract with private dental practices to provide comprehen7 sive oral health services, to low income individuals and in8 dividuals who are underserved with respect to oral health 

9 care. 

10 ‘‘(b) TECHNICAL ASSISTANCE.—The Secretary shall 

11 provide technical assistance to entities receiving grants 

12 under subsection (a) to provide technical assistance to 

13 such entities in order to— 

14 ‘‘(1) with respect to oral health care services, 

15 increase utilization and efficiency and minimize 

16 missed appointments, contract with offsite providers, 

17 recruit providers (including oral health specialists), 

18 and operate programs outside the physical facilities 

19 to take advantage of new systems to improve access 

20 to oral health services; 

21 ‘‘(2) address barriers to access to such services 

22 and conduct targeted outreach to special populations 

23 such as pregnant women, individuals with disabil24 ities, individuals with chronic conditions such as dia25 betes, and individuals residing in long-term care fa26 cilities; or 


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•S 1522 IS

1 ‘‘(3) contract with private dental practices that 

2 will provide oral health services other than preven3 tive oral health care, including restoration and main4 tenance of oral health, in order to meet the need for 

5 oral health services in the community. 

6 ‘‘(c) ELIGIBLE ENTITIES.—To be eligible to receive 

7 a grant under subsection (a), an entity shall— 

8 ‘‘(1) be— 

9 ‘‘(A) a Federally qualified health center 

10 (as defined in section 1861(aa) of the Social 

11 Security Act); 

12 ‘‘(B) a safety net clinic or a free clinic (as 

13 defined by the Secretary); 

14 ‘‘(C) a health care clinic that provides 

15 services to tribal organizations or urban Indian 

16 organizations (as such terms are defined in sec17 tion 4 of the Indian Health Care Improvement 

18 Act); or 

19 ‘‘(D) any other interested public or private 

20 sector health care provider or organization that 

21 the Secretary determines has a demonstrated 

22 history in serving a high number of uninsured 

23 and or low-income individuals or those who lack 

24 ready access to oral health services; and 


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1 ‘‘(2) demonstrate a clear need to expand oral 

2 health care services beyond preventive oral health 

3 care. 

4 ‘‘(d) ALLOCATION FOR HIRING ORAL HEALTH CARE

5 SPECIALISTS.—A portion of the funds available under this 

6 section shall be allocated toward hiring oral health care 

7 specialists, such as oral surgeons and endodontists, at en8 tities receiving grants under this section. 

9 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To 

10 carry out this section, there is authorized to be appro11 priated such sums as may be necessary for each of fiscal 

12 years 2014 through 2017.’’. 

13 SEC. 222. DENTAL CLINICS IN SCHOOLS. 

14 Part Q of title III of the Public Health Service Act 

15 (42 U.S.C. 280h et seq.) is amended by adding at the end 

16 the following: 

17 ‘‘SEC. 399Z–2. DENTAL CLINICS IN SCHOOLS. 

18 ‘‘(a) IN GENERAL.—The Secretary shall award 

19 grants to qualified entities for the purpose of funding the 

20 building, operation, or expansion of dental clinics in 

21 schools. 

22 ‘‘(b) QUALIFIED ENTITIES.—To receive a grant 

23 under this section, a qualified entity shall submit an appli24 cation to the Secretary at such time, in such manner, and 

25 containing such information as the Secretary may require. 


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1 ‘‘(c) REQUIREMENTS.—An entity receiving a grant 

2 under this section shall— 

3 ‘‘(1) provide comprehensive oral health services 

4 at a dental clinic based at a school, including oral 

5 health education, oral screening, fluoride application, 

6 prophylaxis, sealants, and basic restorative services; 

7 ‘‘(2) develop a coordinated system of care by re8 ferring patients to an available qualified oral health 

9 provider in the community for any required oral 

10 health services not provided in the dental clinic in 

11 the school, including restorative services, to ensure 

12 that all the oral health needs of students are met; 

13 and 

14 ‘‘(3) maintain clinic hours that extend beyond 

15 school hours. 

16 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—For 

17 purposes of carrying out this section, there is authorized 

18 to be appropriated such sums as may be necessary for fis19 cal years 2014 through 2017.’’. 

20 SEC. 223. EMERGENCY ROOM CARE COORDINATION. 

21 Part B of title III of the Public Health Service Act 

22 (42 U.S.C. 243 et seq.) is amended by adding at the end 

23 the following: 


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1 ‘‘SEC. 320B. EMERGENCY ROOM CARE COORDINATION WITH 

2 RESPECT TO DENTAL CARE. 

3 ‘‘(a) IN GENERAL.—The Secretary, acting through 

4 the Administrator of the Health Resources and Services 

5 Administration, shall establish a grant program to enable 

6 individuals to receive dental care at a facility operated by 

7 a grant recipient rather than at a hospital emergency 

8 room. 

9 ‘‘(b) ELIGIBLE ENTITIES.—To be eligible to receive 

10 a grant under this section an entity shall— 

11 ‘‘(1) be— 

12 ‘‘(A) a Federally qualified health center 

13 (as defined in paragraph (4) of section 

14 1861(aa) of the Social Security Act) or rural 

15 health clinic (as defined in paragraph (2) of 

16 such section); 

17 ‘‘(B) a private dental practice; or 

18 ‘‘(C) any other interested public or private 

19 sector health care provider or organization, 

20 such as a dental school, that the Secretary de21 termines has the capacity to serve in a coordi22 nated, cost-effective manner, a high number of 

23 individuals who lack access to oral health serv24 ices; and 

25 ‘‘(2) partner with a hospital or urgent care cen26 ter. 


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1 ‘‘(c) ORAL HEALTH EDUCATION FOR PRIMARY CARE

2 AND ER HEALTH CARE PROVIDERS.—The Secretary shall 

3 allocate a portion of the amounts appropriated under sub4 section (e) toward medical education for primary care and 

5 emergency room physicians, nurses, nurse practitioners, 

6 physician assistants, and nurse practitioners to be trained 

7 in oral health. 

8 ‘‘(d) REPORT.—Not later than January 1, 2017, the 

9 Secretary shall submit to Congress a report on the best 

10 practices determined by the program established under 

11 this section to address oral health needs of individuals who 

12 go to emergency rooms in need of oral health care. 

13 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To 

14 carry out this section, there is authorized to be appro15 priated such sums as may be necessary for fiscal years 

16 2014 through 2017.’’. 

17 SEC. 224. RESEARCH FUNDING. 

18 For fiscal years 2014 through 2017, there is author19 ized to be appropriated such sums as may be necessary 

20 to each of— 

21 (1) the Centers for Disease Control and Preven22 tion, for the purpose of conducting research on— 

23 (A) the prevention of oral disease; 

24 (B) oral disease management; and 


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1 (C) evidence-based strategies to prevent 

2 tooth decay; 

3 (2) the Agency for Healthcare Research and 

4 Quality, for the purpose of conducting— 

5 (A) research with respect to oral health 

6 services and the delivery of oral health services; 

7 and 

8 (B) an evaluation of oral health service de9 livery to underserved and vulnerable popu10 lations; 

11 (3) the National Institute of Dental and 

12 Craniofacial Research for the purpose of conducting 

13 research on oral health disease management includ14 ing pharmaceutical-behavioral intervention; and 

15 (4) the Maternal and Child Health Bureau for 

16 the purpose of conducting research on perinatal, 

17 postnatal, and childhood oral health issues. 

18 SEC. 225. MOBILE AND PORTABLE DENTAL SERVICES. 

19 Subpart X of part D of title III of the Public Health 

20 Service Act (42 U.S.C. 256f et seq.), as amended by sec21 tion 221, is further amended by adding at the end the 

22 following: 

23 ‘‘SEC. 340G–3. MOBILE AND PORTABLE DENTAL SERVICES. 

24 ‘‘(a) IN GENERAL.—The Secretary shall award 

25 grants to Federally qualified health centers (as defined in 


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•S 1522 IS

1 paragraph (4) of section 1861(aa) of the Social Security 

2 Act), rural health clinics (as defined in paragraph (2) of 

3 such section), nonprofit dental clinics, and dental schools 

4 to provide mobile and portable, comprehensive dental serv5 ices that provide for the restoration or maintenance of oral 

6 health and function (including dental services provided by 

7 licensed providers through telehealth-enabled collaboration 

8 and supervision) and outreach for dental services to un9 derserved populations. Eligible entities shall deliver such 

10 services at locations such as senior centers, nursing 

11 homes, assisted living facilities, schools, licensed day care 

12 centers that serve eligible individuals who receive benefits 

13 under the State Children’s Health Insurance Program 

14 under title XXI of the Social Security Act (42 U.S.C. 

15 1397aa et seq.) or the Medicaid program under title XIX 

16 of the Social Security Act (42 U.S.C. 1396 et seq.), and 

17 facilities that provide services under the Special Supple18 mental Nutrition Program for Women, Infants, and Chil19 dren (the WIC program) or the Head Start Act (42 U.S.C. 

20 9831 et seq.). The Secretary shall award the grants to 

21 entities that can provide coordinated care and continuity 

22 of care. 

23 ‘‘(b) AUTHORIZATION OF APPROPRIATIONS.—To 

24 carry out this section, there are authorized to be appro25 priated such sums as may be necessary.’’. 


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1 Subtitle D—Oral Health Services as 

2 an Essential Health Benefit 

3 SEC. 231. ORAL HEALTH SERVICES AS AN ESSENTIAL 

4 HEALTH BENEFIT. 

5 Section 1302(b)(1) of the Patient Protection and Af6 fordable Care Act (42 U.S.C. 18022(b)(1)) is amended by 

7 adding at the end the following: 

8 ‘‘(K) Oral health services.’’. 

9 TITLE III—DEPARTMENT OF 

10 VETERANS AFFAIRS AND DE11 PARTMENT OF DEFENSE MAT12 TERS 

13 Subtitle A—Department of 

14 Veterans Affairs Matters 

15 SEC. 301. REQUIRING THE SECRETARY OF VETERANS AF16 FAIRS TO FURNISH DENTAL CARE IN THE 

17 SAME MANNER AS ANY OTHER MEDICAL 

18 SERVICE. 

19 (a) IN GENERAL.—Title 38, United States Code, is 

20 amended— 

21 (1) in section 1701(6), by striking ‘‘as de22 scribed in sections 1710 and 1712 of this title’’; 

23 (2) in section 1710(c), by striking the second 

24 sentence; 

25 (3) in section 1712— 


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1 (A) by striking subsections (a) and (b); 

2 (B) by redesignating subsections (c), (d), 

3 and (e) as subsections (a), (b), and (c), respec4 tively; and 

5 (C) in subsection (a), as redesignated by 

6 subparagraph (B)— 

7 (i) by striking ‘‘Dental appliances’’ 

8 and inserting ‘‘The Secretary may furnish 

9 dentures, dental appliances’’; and 

10 (ii) by striking ‘‘to be furnished by the 

11 Secretary under this section may be pro12 cured by the Secretary’’ and inserting 

13 ‘‘under this section and may procure such 

14 appliances’’; and 

15 (4) by striking section 2062. 

16 (b) CONFORMING AMENDMENTS.—Such title is fur17 ther amended— 

18 (1) in section 1525(a), by striking ‘‘medicines 

19 under section 1712(d)’’ and inserting ‘‘medicines 

20 under section 1712(b)’’; and 

21 (2) in section 1703(a)(7), by striking ‘‘, for a 

22 veteran described in section 1712(a)(1)(F) of this 

23 title’’. 

24 (c) CLERICAL AMENDMENTS.—Such title is further 

25 amended— 


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1 (1) in section 1712, in the heading for such sec2 tion, by striking ‘‘Dental care’’ and inserting 

3 ‘‘Appliances’’; 

4 (2) in the table of sections at the beginning of 

5 chapter 17, by striking the item relating to section 

6 1712 and inserting the following new item: 

‘‘1712. Appliances; drugs and medicines for certain disabled veterans; vaccines.’’; 

7 and 

8 (3) in the table of sections at the beginning of 

9 chapter 20, by striking the item relating to section 

10 2062. 

11 SEC. 302. DEMONSTRATION PROGRAM ON TRAINING AND 

12 EMPLOYMENT OF ALTERNATIVE DENTAL 

13 HEALTH CARE PROVIDERS FOR DENTAL 

14 HEALTH CARE SERVICES FOR VETERANS IN 

15 RURAL AND OTHER UNDERSERVED COMMU16 NITIES. 

17 (a) DEMONSTRATION PROGRAM AUTHORIZED.—The 

18 Secretary of Veterans Affairs may carry out a demonstra19 tion program to establish programs to train and employ 

20 alternative dental health care providers in order to in21 crease access to dental health care services for veterans 

22 entitled to such services who reside in rural and other un23 derserved communities. 


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1 (b) TELEHEALTH.—For purposes of alternative den2 tal health care providers and any other dental care pro3 viders who are licensed to provide clinical care, dental 

4 services provided under the demonstration program under 

5 this section may be administered by such providers 

6 through telehealth-enabled collaboration and supervision 

7 when deemed appropriate and feasible. 

8 (c) ALTERNATIVE DENTAL HEALTH CARE PRO9 VIDERS DEFINED.—In this section, the term ‘‘alternative 

10 dental health care providers’’ has the meaning given that 

11 term in section 340G–1(a)(2) of the Public Health Service 

12 Act (42 U.S.C. 256g–1(a)(2)). 

13 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

14 are authorized to be appropriated such sums as are nec15 essary to carry out the demonstration program under this 

16 section. 


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1 Subtitle B—Department of Defense 

2 Matters 

3 SEC. 311. DEMONSTRATION PROGRAM ON TRAINING AND 

4 EMPLOYMENT OF ALTERNATIVE DENTAL 

5 HEALTH CARE PROVIDERS FOR DENTAL 

6 HEALTH CARE SERVICES FOR MEMBERS OF 

7 THE ARMED FORCES AND DEPENDENTS 

8 LACKING READY ACCESS TO SUCH SERVICES. 

9 (a) DEMONSTRATION PROGRAM AUTHORIZED.—The 

10 Secretary of Defense may carry out a demonstration pro11 gram to establish programs to train and employ alter12 native dental health care providers in order to increase ac13 cess to dental health care services for members of the 

14 Armed Forces and their dependents who lack ready access 

15 to such services, including the following: 

16 (1) Members and dependents who reside in 

17 rural areas or areas otherwise underserved by dental 

18 health care providers. 

19 (2) Members of the National Guard and Re20 serves in active status who are potentially 

21 deployable. 

22 (b) TELEHEALTH.—For purposes of alternative den23 tal health care providers and any other dental care pro24 viders who are licensed to provide clinical care, dental 

25 services provided under the demonstration program under 


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1 this section may be administered by such providers 

2 through telehealth-enabled collaboration and supervision 

3 when deemed appropriate and feasible. 

4 (c) ALTERNATIVE DENTAL HEALTH CARE PRO5 VIDERS DEFINED.—In this section, the term ‘‘alternative 

6 dental health care providers’’ has the meaning given that 

7 term in section 340G–1(a)(2) of the Public Health Service 

8 Act (42 U.S.C. 256g–1(a)(2)). 

9 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

10 are authorized to be appropriated such sums as are nec11 essary to carry out the demonstration program under this 

12 section. 

13 TITLE IV—FEDERAL BUREAU OF 

14 PRISONS 

15 SEC. 401. DEMONSTRATION PROGRAM ON TRAINING AND 

16 EMPLOYMENT OF ALTERNATIVE DENTAL 

17 HEALTH CARE PROVIDERS FOR DENTAL 

18 HEALTH CARE SERVICES FOR PRISONERS 

19 WITHIN THE CUSTODY OF THE BUREAU OF 

20 PRISONS. 

21 (a) DEMONSTRATION PROGRAM AUTHORIZED.—The 

22 Attorney General, acting through the Director of the Bu23 reau of Prisons, may carry out a demonstration program 

24 to establish programs to train and employ alternative den25 tal health care providers in order to increase access to denVerDate Mar 15 2010 03:58 Sep 19, 2013 Jkt 029200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6201 E:\BILLS\S1522.IS S1522

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1 tal health services for prisoners within the custody of the 

2 Bureau of Prisons. 

3 (b) TELEHEALTH.—For purposes of alternative den4 tal health care providers and any other dental care pro5 viders who are licensed to provide clinical care, dental 

6 services provided under the demonstration program under 

7 this section may be administered by such providers 

8 through telehealth-enabled collaboration and supervision 

9 when deemed appropriate and feasible. 

10 (c) ALTERNATIVE DENTAL HEALTH CARE PRO11 VIDERS DEFINED.—In this section, the term ‘‘alternative 

12 dental health care providers’’ has the meaning given that 

13 term in section 340G–1(a)(2) of the Public Health Service 

14 Act (42 U.S.C. 256g–1(a)(2)). 

15 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

16 are authorized to be appropriated such sums as are nec17 essary to carry out the demonstration program under this 

18 section. 


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1 TITLE V—INDIAN HEALTH 

2 SERVICE 

3 SEC. 501. DEMONSTRATION PROGRAM ON TRAINING AND 

4 EMPLOYMENT OF ALTERNATIVE DENTAL 

5 HEALTH CARE PROVIDERS FOR DENTAL 

6 HEALTH CARE SERVICES UNDER THE INDIAN 

7 HEALTH SERVICE. 

8 (a) DEMONSTRATION PROGRAM AUTHORIZED.—The 

9 Secretary of Health and Human Services, acting through 

10 the Indian Health Service, may carry out a demonstration 

11 program to establish programs to train and employ alter12 native dental health care providers in order to help elimi13 nate oral health disparities and increase access to dental 

14 services through health programs operated by the Indian 

15 Health Service, Indian tribes, tribal organizations, and 

16 Urban Indian organizations (as those terms are defined 

17 in section 4 of the Indian Health Care Improvement Act 

18 (25 U.S.C. 1603)). 

19 (b) TELEHEALTH.—For purposes of alternative den20 tal health care providers and any other dental care pro21 viders who are licensed to provide clinical care, dental 

22 services provided under the demonstration program under 

23 this section may be administered by such providers 

24 through telehealth-enabled collaboration and supervision 

25 when deemed appropriate and feasible. 


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1 (c) ALTERNATIVE DENTAL HEALTH CARE PRO2 VIDERS DEFINED.—In this section, the term ‘‘alternative 

3 dental health care providers’’ has the meaning given that 

4 term in section 340G–1(a)(2) of the Public Health Service 

5 Act (42 U.S.C. 256g–1(a)(2)). 

6 (d) AUTHORIZATION OF APPROPRIATIONS.—There 

7 are authorized to be appropriated such sums as are nec8 essary to carry out the demonstration program under this 

9 section. 

10 TITLE VI—REPORTS TO 

11 CONGRESS 

12 SEC. 601. EVALUATION OF EXPANSION OF COVERAGE FOR 

13 DENTAL SERVICES. 

14 (a) SECRETARY OF HEALTH AND HUMAN SERV15 ICES.—Not later than October 1, 2017, the Secretary of 

16 Health and Human Services shall submit to Congress a 

17 report that provides a comprehensive cost-benefit analysis 

18 regarding the expansion of coverage for dental services 

19 pursuant to this Act, including whether the provision of 

20 such services resulted in a reduction in total health care 

21 costs for individuals under the Medicare and Medicaid 

22 programs. 

23 (b) COMPTROLLER GENERAL.— 

24 (1) MEDICAID AND MEDICARE.—Not later than 

25 January 1, 2017, the Comptroller General of the 


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1 United States shall submit to Congress a report that 

2 provides a comprehensive analysis and evaluation of 

3 the implementation and utilization of the expanded 

4 coverage for dental services pursuant to this Act for 

5 individuals enrolled in the Medicare and Medicaid 

6 programs. 

7 (2) DEMONSTRATION PROGRAMS.—Not later 

8 than January 1, 2017, the Comptroller General of 

9 the United States shall submit to Congress a report 

10 that provides a comprehensive analysis and evalua11 tion of the demonstration programs described in sec12 tions 302, 311, 401, and 501, including— 

13 (A) the extent to which the programs im14 proved access to oral health care and increased 

15 utilization of oral health services; and 

16 (B) an examination of the training pro17 vided under the programs to alternative dental 

18 health care providers and the quality of care 

19 provided by such providers. 

Æ 


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