SMILED Act

To amend title XIX of the Social Security Act to improve oral health care and dental benefits under the Medicaid program, and for other purposes. 1. Short title This Act may be cited as the Strengthening Medicaid Incentives for Licensees Enrolled in Dental Act SMILED Act 2. Support for ensuring individuals enrolled in Medicaid have dental services access equal to the population of the State Section 1903 of the Social Security Act ( 42 U.S.C. 1396b (cc) Equal access to oral health care plan (1) Provider participation and access requirements Not later than 1 year after the date of enactment of this paragraph, a State shall provide the Secretary with assurances that administrative barriers to the participation of licensed dentists under this title will be addressed, by— (A) improving eligibility verification; (B) ensuring that any such dentist may participate in a publicly funded plan without also having to participate in any other plan; (C) simplifying claims forms processing; and (D) assigning a single plan administrator for the dental program. (2) Study on dentist participation Not later than 3 years after the date on which the assurance under paragraph (1) is submitted, each State shall conduct a study to determine whether the participation of licensed dentists have increased following the assurance provided under paragraph (1). . 3. Dental and oral health services defined; audit requirement (a) Dental and oral health services defined Section 1905 of the Social Security Act ( 42 U.S.C. 1396d (1) in subsection (a)(10), by inserting and dental and oral health services (as defined in subsection (jj)) dental services (2) by adding at the end the following new subsection: (jj) Dental and oral health services (1) In general For purposes of subsection (a)(10), the term dental and oral health services (A) is legally authorized to furnish such items and services under State law (or the State regulatory mechanism provided by State law); (B) is initially credentialed by a State Medicaid program (or the designated entity of such program) through an integrated data collection system, as described in paragraph (3); and (C) is, as applicable, re-credentialed through such integrated data collection system by a State Medicaid program (or the designated entity of such program). (2) Selection of data collection system Not later than one year after the date of enactment of this subsection, the State Medicaid Director shall select an integrated data collection system (as defined in paragraph (3) that— (A) minimizes provider paperwork burden; and (B) communicates final credentialing decisions to providers within 90 days of receipt of a completed application. (3) Integrated data collection system defined For purposes of this subsection, the term integrated data collection system . (b) Dental and oral health services audit requirement Not later than 90 days after the date of enactment of this Act, a State Medicaid program, including a program offered by a sponsor of a Medicaid managed care plan, that offers dental and oral health services audits a claim for such dental and oral health services shall— (1) utilize a licensed health care professional from the dental specialty area of practice being audited to establish relevant audit methodology consistent with— (A) established practice guidelines, standards of care, and State-issued dental Medicaid provider handbooks; and (B) established clinical practice guidelines and acceptable standards of care established by the dental professional or specialty organizations responsible for setting such standards of care; (2) develop and implement, in consultation with the Centers for Medicare & Medicaid Services, a procedure in which an improper payment identified by an audit may be resubmitted as a claims adjustment, including the resubmission of— (A) claims denied as a result of an interpretation of scope of services not previously held by the Centers for Medicare & Medicaid Services; (B) documentation when the document provided is incomplete, illegible, or unclear; and (C) documentation when clerical errors resulted in a denial of claims for services actually provided; and (3) disallow the difference between the payment for the service that was provided and the payment for the service that should have been provided if a service was provided and sufficiently documented, but denied because it was determined that a different service should have been billed.

Summary: Strengthening Medicaid Incentives for Licensees Enrolled in Dental Act or the SMILED Act This bill requires state Medicaid programs to implement certain measures to improve the participation of dentists and the processing of related claims under Medicaid. Specifically, states must assure the Centers for Medicare &amp; Medicaid Services that they will address dentist participation by improving eligibility verification and simplifying participation requirements and claims administration. States must also (1) use an electronic, integrated data collection system to credential participating dentists within 90 days of application receipt; and (2) develop procedures for conducting audits that are consistent with practice standards and that allow for improper claims to be rectified through claims adjustments.