March 11 (legislative day, March 10), 2025
Mr. Sanders (for himself, Ms. Warren, Mr. Booker, Mr. Welch, Mr. Markey, Ms. Duckworth, Mr. Merkley, and Mr. Blumenthal) introduced the following bill; which was read twice and referred to the Committee on Finance
To amend title XVIII of the Social Security Act to provide coverage for dental and oral health care, hearing care, and vision care under the Medicare program.
Section 1. Short title
This Act may be cited as the Medicare Dental, Hearing, and Vision Expansion Act of 2025
.
Sec. 2. Coverage of 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 (JJ), by adding and
at the end; and
(2)
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:
(nnn) Dental and oral health services
(1) In general
Except as provided in paragraph (2), the term
dental and oral health servicesmeans the following items and services that are furnished by a doctor of dental surgery or of dental medicine (as described in subsection (r)(2)) or an oral health professional (as defined in paragraph (3)) on or after January 1, 2027 (or January 1, 2026, in the case of dentures):(A) Preventive and screening services
Preventive and screening services, including oral exams, dental cleanings, dental x-rays, and fluoride treatments.
(B) Procedures and treatment services
Services to address oral disease, including services such as restorative services, prosthodontic and endodontic services, including fillings bridges, crowns, and root canals, periodontal maintenance, periodontal scaling and root planing, tooth extractions, therapeutic pulpotomy, and other related items and services.
(C) Dentures and dental prosthetics
Complete dentures, partial dentures, and implants, including related items and services.
(2) Exclusions
Such term does not include items and services for which, as of the date of the enactment of this subsection, coverage was permissible under section 1862(a)(12) and cosmetic services not otherwise covered under section 1862(a)(10).
(3) Oral health professional
The term oral health professional means, with respect to dental and oral health services, a health professional (other than a doctor of dental surgery or of dental medicine (as described in subsection (r)(2))) who is licensed to furnish such services, acting within the scope of such license, by the State in which such services are furnished.
(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)
in subparagraph (N), by inserting and dental and oral health services (as defined in section 1861(nnn))
after section 1861(hhh)(1))
;
(B)
by striking and
before (HH)
; and
(C)
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) Payment
The payment amount under this part for dental and oral health services (as defined in section 1861(nnn)) shall be, subject to paragraphs (3) and (4), 80 percent (or 100 percent, in the case of preventive and screening services described in section 1861(nnn)(1)(A)) of the lesser of—
(A)
the actual charge for the service; or
(B)
(i)
in the case of such services furnished by a doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)), the amount determined under the fee schedule established under paragraph (2); or
(ii)
in the case of such services furnished by an oral health professional (as defined in section 1861(nnn)(3)), 85 percent of the amount determined under the fee schedule established under paragraph (2).
(2) Establishment of fee schedule for dental and oral health services
(A) Establishment
(i) In general
The Secretary shall establish a fee schedule for dental and oral health services furnished in 2027 (or 2026, in the case of dentures) and subsequent years. The fee schedule amount for a dental or oral health service shall be equal to 70 percent of the national median fee (as determined under subparagraph (B)) for the service or a similar service for the year (or, in the case of dentures, at the bundled payment amount under clause (iv) of such subparagraph), adjusted by the geographic adjustment factor established under section 1848(e)(2) for the area for the year.
(ii) Consultation
In carrying out this paragraph, the Secretary shall consult annually with organizations representing dentists and other providers who furnish dental and oral health services and shall share with such providers the data and data analysis used to determine fee schedule amounts under this paragraph.
(B) Determination of national median fee
(i) In general
For purposes of subparagraph (A), the Secretary shall apply the national median fee for a dental or oral health service for 2027 (or 2026, in the case of dentures) and subsequent years in accordance with this subparagraph.
(ii) Use of 2020 dental fee survey
(I) In general
Except as provided in clause (iii) and clause (iv), the national median fee for a dental or oral health service shall be equal to—
(aa)
for 2027 (or 2026, in the case of dentures), the median fee for the service in the table titled
General Practitioners–Nationalof the2020 Survey of Dental Feespublished by the American Dental Association, increased by the applicable percent increase for the year determined under subclause (II), as reduced by the productivity adjustment under subclause (III); and(bb)
for 2028 (or 2027, in the case of dentures) and subsequent years, the amount determined under this subclause for the preceding year, updated pursuant to subparagraph (C)(i).
(II) Applicable percent increase
The applicable percent increase determined under this subclause for a year is an amount equal to the percentage increase between—
(aa)
the consumer price index for all urban consumers (United States city average) ending with June of the previous year; and
(bb)
the consumer price index for all urban consumers (United States city average) ending with June of 2026 (or 2025, in the case of dentures).
(III) Productivity adjustment
After determining the applicable percentage increase under subclause (II) for a year, the Secretary shall reduce such percentage increase by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II).
(iii) Determination if insufficient survey data
If the Secretary determines there is insufficient data under the Survey described in clause (ii) with respect to a dental or oral health service, the national median fee for the service for a year shall be equal to an amount established for the service using 1 or more of the following methods, as determined appropriate by the Secretary:
(I)
The payment basis determined under section 1848.
(II)
Fee schedules for dental and oral health services which shall include, as practicable, fee schedules—
(aa)
under Medicare Advantage plans under part C;
(bb)
under State plans (or waivers of such plans) under title XIX; and
(cc)
established by other health care payers.
(iv) Special rule for dentures
(I) In general
The Secretary shall make payment for dentures and associated professional services as a bundled payment as determined by the Secretary.
(II) Payment considerations
In establishing such bundled payment, the Secretary shall consider the national median fee for the service for the year determined under clause (ii) or (iii) and the rate determined for such dentures under the Federal Supply Schedule of the General Services Administration, as published by such Administration in 2021, updated to the year involved using the applicable percent increase for the year determined under clause (ii)(II), as reduced by the productivity adjustment under clause (ii)(III), and shall ensure that the payment component for dentures under such bundled payment does not exceed the maximum rate determined for such dentures under the Federal Supply Schedule, as so published and updated to the year involved.
(C) Annual update and adjustments
(i) Annual update
The Secretary shall update payment amounts determined under the fee schedule from year to year beginning in 2028 (or 2027, in the case of dentures) by increasing such amounts from the prior year by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II).
(ii) Adjustments
(I) In general
The Secretary shall, to the extent the Secretary determines to be necessary and subject to subclause (II), adjust the amounts determined under the fee schedule established under this paragraph for 2028 (or 2027, in the case of dentures) and subsequent years to take into account changes in dental practice, coding changes, new data on work, practice, or malpractice expenses, or the addition of new procedures.
(II) Limitation on annual adjustments
The adjustments under subclause (I) for a year shall not cause the amount of expenditures under this part for the year to differ by more than $20,000,000 from the amount of expenditures under this part that would have been made if such adjustments had not been made.
(3) Limitations
With respect to dental and oral health services that are preventive and screening services described in paragraph (1)(A) of section 1861(nnn)—
(A)
payment shall be made under this part for—
(i)
not more than 2 oral exams in a year;
(ii)
not more than 2 dental cleanings in a year;
(iii)
not more than 1 fluoride treatment in a year; and
(iv)
not more than 1 full-mouth series of x-rays as part of a preventive and screening oral exam every 3 years; and
(B)
in the case of preventive and screening services not described in subparagraph (A), payment shall be made under this part only at such frequencies determined appropriate by the Secretary.
(4) Incentives for rural providers
In the case of dental and oral health services furnished by a doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)) or an oral health professional (as defined in section 1861(nnn)(3)) who predominantly furnishes such services under this part in an area that is designated by the Secretary (under section 332(a)(1)(A) of the Public Health Service Act) as a health professional shortage area, in addition to the amount of payment that would otherwise be made for such services under this subsection, there also shall be paid an amount equal to 10 percent of the payment amount for the service under this subsection for such doctor or professional.
(5) Limitation on beneficiary liability
The provisions of section 1848(g) shall apply to a nonparticipating doctor of dental surgery or of dental medicine (as described in section 1861(r)(2)) who does not accept payment on an assignment-related basis for dental and oral health services furnished with respect to an individual enrolled under this part in the same manner as such provisions apply with respect to a physician's service.
(6) Establishment of dental administrator
The Secretary shall designate 1 or more (not to exceed 4) medicare administrative contractors under section 1874A to establish coverage policies and establish such policies and process claims for payment for dental and oral health services, as determined appropriate by the Secretary.
(d) Inclusion of oral health professionals as certain practitioners
Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clause:
(ix)
With respect to 2028 and each subsequent year, an oral health professional (as defined in section 1861(nnn)(3)).
(e) Exclusion modifications
Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended—
(1)
in paragraph (1)—
(A)
in subparagraph (O), by striking and
at the end;
(B)
in subparagraph (P), by striking the semicolon at the end and inserting , and
; and
(C)
by adding at the end the following new subparagraph:
(Q)
in the case of dental and oral health services (as defined in section 1861(nnn)) for which a limitation is applicable under section 1834(aa)(3), which are furnished more frequently than is provided under such section;; and
(2)
in paragraph (12), by inserting before the semicolon at the end the following: and except that payment shall be made under part B for dental and oral health services that are covered under section 1861(s)(2)(KK)
.
(f) Inclusion as excepted medical treatment
Section 1821(b)(5)(A) of the Social Security Act (42 U.S.C. 1395i–5(b)(5)(A)) is amended—
(1)
in clause (ii), by striking or
at the end;
(2)
in clause (iii), by striking the period and inserting , or
; and
(3)
by adding at the end the following new clause:
(iv)
consisting of dental and oral health services (as defined in subsection (mmm) of section 1861) that are payable under part B as a result of the amendments made by the Medicare Dental, Hearing, and Vision Expansion Act of 2025.
(g) Rural health clinics and federally qualified health centers
(1) Coverage of dental and oral health services
Section 1861(aa) of the Social Security Act (42 U.S.C. 1395x(aa)), is amended—
(A)
in paragraph (1)—
(i)
in subparagraph (C), by striking and
at the end;
(ii)
in subparagraph (D), by inserting and
after the comma at the end; and
(iii)
by inserting after subparagraph (D) the following new subparagraph:
(E)
dental and oral health services (as defined in subsection (nnn)) furnished by a doctor of dental surgery or of dental medicine (as described in subsection (r)(2)) or an oral health professional (as defined in subsection (nnn)(3)) who is employed by or working under contract with a rural health clinic if such rural health clinic furnishes such services,; and
(B)
in paragraph (3)(A), by striking (D)
and inserting (E)
.
(2) Temporary payment rates for certain services under the RHC AIR and FQHC PPS
(A) AIR
Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended—
(i)
in subsection (a)(3)(A), by inserting (which shall, in the case of dental and oral health services (as defined in section 1861(nnn)), in lieu of any limits on reasonable costs otherwise applicable, be based on the rates payable for such services under the payment basis determined under section 1848 until such time as the Secretary determines sufficient data has been collected to otherwise apply such limits (or January 1, 2031, if no such determination has been made as of such date))
after may prescribe in regulations
; and
(ii)
by adding at the end the following new subsection:
(ee) Disregard of costs attributable to certain services from calculation of RHC AIR
Payments for rural health clinic services other than dental and oral health services (as defined in section 1861(nnn)) under the methodology for all-inclusive rates (established by the Secretary) under subsection (a)(3) shall not take into account the costs of such services while rates for such services are based on rates payable for such services under the payment basis established under section 1848.
(B) PPS
Section 1834(o) of the Social Security Act (42 U.S.C. 1395m(o)) is amended by adding at the end the following new paragraph:
(6) Temporary payment rates based on pfs for certain services
The Secretary shall, in establishing payment rates for dental and oral health services (as defined in section 1861(nnn)) that are Federally qualified health center services under the prospective payment system established under this subsection, in lieu of the rates otherwise applicable under such system, base such rates on rates payable for such services under the payment basis established under section 1848 until such time as the Secretary determines sufficient data has been collected to otherwise establish rates for such services under such system (or January 1, 2031, if no such determination has been made as of such date). Payments for Federally qualified health center services other than such dental and oral health services under such system shall not take into account the costs of such services while rates for such services are based on rates payable for such services under the payment basis established under section 1848.
(h) Implementation
In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2025, out of any money in the Treasury not otherwise appropriated, $900,000,000, to remain available until expended, for purposes of implementing the amendments made by this section during the period beginning on January 1, 2025, and ending on September 30, 2034.
Sec. 3. Providing coverage for hearing care under the Medicare program
(a) Provision of audiology services by qualified audiologists and hearing aid examination services by qualified hearing aid professionals
(1) In general
Section 1861(ll) of the Social Security Act (42 U.S.C. 1395x(ll)) is amended—
(A)
in paragraph (3)—
(i)
by inserting (A)
after (3)
;
(ii)
in subparagraph (A), as added by clause (i) of this subparagraph—
(I)
by striking means such hearing and balance assessment services
and inserting “means—
(i)
such hearing and balance assessment services and, beginning January 1, 2027, such hearing aid examination services and treatment services (including aural rehabilitation, vestibular rehabilitation, and cerumen management);
(II)
in clause (i), as added by subclause (I) of this clause, by striking the period at the end and inserting ; and
; and
(III)
by adding at the end the following new clause:
(ii)
beginning January 1, 2027, such hearing aid examination services furnished by a qualified hearing aid professional (as defined in paragraph (4)(C)) as the professional is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise be covered if furnished by a physician.; and
(iii)
by adding at the end the following new subparagraph:
(B)
Beginning January 1, 2027, audiology services described in subparagraph (A)(i) shall be furnished without a requirement for an order from a physician or practitioner.; and
(B)
in paragraph (4), by adding at the end the following new subparagraph:
(C)
The term qualified hearing aid professional means an individual who—
(i)
is licensed or registered as a hearing aid dispenser, hearing aid specialist, hearing instrument dispenser, or related professional by the State in which the individual furnishes such services; and
(ii)
is accredited by the National Board for Certification in Hearing Instrument Sciences or meets such other requirements as the Secretary determines appropriate (including requirements relating to educational certifications or accreditations) taking into account any additional relevant requirements for hearing aid specialists, hearing aid dispensers, and hearing instrument dispensers established by Medicare Advantage organizations under part C, State plans (or waivers of such plans) under title XIX, and group health plans and health insurance issuers (as such terms are defined in section 2791 of the Public Health Service Act).
(2) Payment for qualified hearing aid professionals
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 hearing aid examination services (as described in paragraph (3)(A)(ii) of section 1861(ll)) furnished by a qualified hearing aid professional (as defined in paragraph (4)(C) of such section), the amounts paid shall be equal to 80 percent of the lesser of the actual charge for such services or 85 percent of the amount for such services determined under the payment basis determined under section 1848
.
(3) Inclusion of qualified audiologists and qualified hearing aid professionals as certain practitioners to receive payment on an assignment-related basis
(A) Qualified audiologists
Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by section 2(d), is amended by adding at the end the following new clause:
(x)
Beginning on January 1, 2027, a qualified audiologist (as defined in section 1861(ll)(4)(B)).
(B) Qualified hearing aid professionals
Section 1842(b)(18) of the Social Security Act (42 U.S.C. 1395u(b)(18)) is amended—
(i)
in each of subparagraphs (A) and (B), by striking subparagraph (C)
and inserting subparagraph (C) or, beginning on January 1, 2027, subparagraph (E)
; and
(ii)
by adding at the end the following new subparagraph:
(E)
A practitioner described in this subparagraph is a qualified hearing aid professional (as defined in section 1861(ll)(4)(C)).
(b) Coverage of hearing aids
(1) Inclusion of hearing aids as prosthetic devices
Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)) is amended by inserting , and including hearing aids (as described in section 1834(h)(7)) furnished on or after January 1, 2027, to individuals with moderately severe, severe, or profound hearing loss
before the semicolon at the end.
(2) Payment limitations for hearing aids
Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraphs:
(6) Payment only on an assignment-related basis
Payment for hearing aids for which payment may be made under this part may be made only on an assignment-related basis. The provisions of subparagraphs (A) and (B) of section 1842(b)(18) shall apply to hearing aids in the same manner as they apply to services furnished by a practitioner described in subparagraph (C) of such section.
(7) Limitations for hearing aids
(A) In general
Payment may be made under this part with respect to an individual, with respect to hearing aids furnished by a qualified hearing aid supplier (as defined in subparagraph (C)) on or after January 1, 2027—
(i)
not more than once per ear during a 5-year period;
(ii)
only for types of such hearing aids that are determined appropriate by the Secretary; and
(iii)
only if furnished pursuant to a written order of a physician, qualified audiologist (as defined in section 1861(ll)(4)), qualified hearing aid professional (as defined in subparagraph (C) of such section), physician assistant, nurse practitioner, or clinical nurse specialist.
(B) Special rule
The payment basis determined under this subsection (including after application of paragraph (1)(H), relating to application of competitive acquisition) for hearing aids furnished by a qualified hearing aid supplier on or after January 1, 2027, shall not exceed the rate determined for such hearing aids under the Federal Supply Schedule of the General Services Administration, as published by such Administration in 2021, updated to the year involved using the applicable percent increase for the year.
(C) Definitions
In this subsection:
(i) Hearing aid
The term hearing aid means the item and related services including selection, fitting, adjustment, and patient education and training.
(ii) Qualified hearing aid supplier
The term qualified hearing aid supplier means—
(I)
a qualified audiologist;
(II)
a physician (as defined in section 1861(r)(1));
(III)
a physician assistant, nurse practitioner, or clinical nurse specialist;
(IV)
a qualified hearing aid professional (as defined in section 1861(ll)(4)(C)); and
(V)
other suppliers as determined by the Secretary.
(3) Application of competitive acquisition
(A) In general
Section 1834(h)(1)(H) of the Social Security Act (42 U.S.C. 1395m(h)(1)(H)) is amended—
(i)
in the header, by inserting and hearing aids
after orthotics
;
(ii)
in the matter preceding clause (i), by inserting or of hearing aids described in paragraph (2)(D) of such section,
after 2011,
; and
(iii)
in clause (i), by inserting or such hearing aids
after such orthotics
.
(B) Conforming amendments
(i) In general
Section 1847(a)(2) of the Social Security Act (42 U.S.C. 1395w–3(a)(2)) is amended by adding at the end the following new subparagraph:
(E) Hearing aids
Hearing aids described in section 1861(s)(8) for which payment would otherwise be made under section 1834(h).
(ii) Exemption of certain items from competitive acquisition
Section 1847(a)(7) of the Social Security Act (42 U.S.C. 1395w–3(a)(7)) is amended by adding at the end the following new subparagraph:
(C) Certain hearing aids
Those items and services described in paragraph (2)(E) if furnished by a physician or other practitioner (as defined by the Secretary) to the physician's or practitioner's own patients as part of the physician's or practitioner's professional service.
(iii) Implementation
Section 1847(a) of the Social Security Act (42 U.S.C. 1395w–3(a)) is amended by adding at the end the following new paragraph:
(8) Competition with respect to hearing aids
Not later than January 1, 2031, the Secretary shall begin the competition with respect to the items and services described in paragraph (2)(E).
(4) Physician self-referral law
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)) is amended by adding at the end the following new paragraph:
(6) Hearing aids and services
In the case of hearing aid examination services and hearing aids—
(A)
furnished on or after January 1, 2027, and before January 1, 2029; and
(B)
furnished on or after January 1, 2029, if the financial relationship specified in subsection (a)(2) meets such requirements the Secretary imposes by regulation to protect against program or patient abuse.
(c) Exclusion modification
Section 1862(a)(7) of the Social Security Act (42 U.S.C. 1395y(a)(7)) is amended by inserting (except such hearing aids or examinations therefor as described in and otherwise allowed under section 1861(s)(8))
after hearing aids or examinations therefor
.
(d) Inclusion as excepted medical treatment
Section 1821(b)(5)(A)(iv) of the Social Security Act (42 U.S.C. 1395i–5(b)(5)(A)(iv)), as added by section 2(f), is amended by inserting , audiology services described in subsection (ll)(3) of such section, or hearing aids described in subsection (s)(8) of such section
after section 1861)
.
(e) Rural health clinics and federally qualified health centers
(1) Clarifying coverage of audiology services as physicians' services
Section 1861(aa)(1)(A) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(A)) is amended by inserting (including audiology services (as defined in subsection (ll)(3)))
after physicians' services
.
(2) Inclusion of qualified audiologists and qualified hearing aid professionals as RHC and FQHC practitioners
Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by inserting or by a qualified audiologist or a qualified hearing aid professional (as such terms are defined in subsection (ll)),
after (as defined in subsection (hh)(1)),
.
(3) Temporary payment rates for certain services under the RHC AIR and FQHC PPS
(A) AIR
Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by section 2(g)(2)(A), is amended—
(i)
in subsection (a)(3)(A), by inserting or audiology services (as defined in section 1861(ll)(3))
after (as defined in section 1861(nnn)
; and
(ii)
in subsection (ee), by inserting or audiology services (as defined in section 1861(ll)(3))
after (as defined in section 1861(nnn)
.
(B) PPS
Section 1834(o)(6) of the Social Security Act (42 U.S.C. 1395m(o)(6)), as added by section 2(g)(2)(B), is amended—
(i)
in the first sentence, by inserting or audiology services (as defined in section 1861(ll)(3))
after (as defined in section 1861(nnn))
; and
(ii)
in the second sentence, by inserting or such audiology services
after such dental and oral health services
.
(f) Expediting implementation
The Secretary of Health and Human Services shall implement this section for 2027 and 2028 through program instruction or other forms of program guidance.
(g) Funding
In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2025, out of any money in the Treasury not otherwise appropriated, $370,000,000, to remain available until expended, for purposes of implementing the amendments made by this section during the period beginning on January 1, 2026, and ending on September 30, 2035.
Sec. 4. Providing coverage for vision care under the Medicare program
(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 striking the period at the end and adding ; and
; and
(3)
by adding at the end the following new subparagraph:
(LL)
vision services (as defined in subsection (ooo));
(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:
(ooo) Vision services
The term vision services means routine eye examinations to determine the refractive state of the eyes, including procedures performed during the course of such examination, furnished on or after January 1, 2027, by or under the direct supervision of an ophthalmologist or optometrist who is legally authorized to furnish such examinations or procedures (as applicable) under State law (or the State regulatory mechanism provided by State law) of the State in which the examinations or procedures are furnished.
(c) Payment limitations
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) Limitation for vision services
With respect to vision services (as defined in section 1861(ooo)) and an individual, payment shall be made under this part for only 1 routine eye examination described in such subsection during a 2-year period.
(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)(LL),
before (3)
.
(e) Coverage of conventional eyeglasses
Section 1861(s)(8) of the Social Security Act (42 U.S.C. 1395x(s)(8)), as amended by section 3(b)(1), is amended by striking , and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens
and inserting , including 1 pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens, if furnished before January 1, 2027, and including conventional eyeglasses (as described in section 1834(h)(8)), whether or not furnished subsequent to such a surgery, if furnished on or after January 1, 2027
.
(f) Special payment rules for eyeglasses
(1) Limitations
Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)), as amended by section 3(b)(2), is amended by adding at the end the following new paragraph:
(8) Payment limitations for eyeglasses
(A) In general
With respect to conventional eyeglasses furnished to an individual on or after January 1, 2027, subject to subparagraph (B), payment shall be made under this part only during a 2-year period, for 1 pair of eyeglasses (including lenses and the frame).
(B) Exception
With respect to a 2-year period described in subparagraph (A), in the case of an individual who receives cataract surgery with insertion of an intraocular lens, payment shall be made under this part for 1 pair of conventional eyeglasses furnished subsequent to such cataract surgery during such period.
(C) Special rule
The payment basis determined under this subsection (including after application of paragraph (1)(H), relating to application of competitive acquisition) for conventional eyeglasses furnished to an individual on or after January 1, 2027, shall not exceed the rate determined for such eyeglasses under the Federal Supply Schedule of the General Services Administration, as published by such Administration in 2021, updated to the year involved using the applicable percent increase for the year.
(D) No coverage of certain items
Payment shall not be made under this part for deluxe eyeglasses or conventional reading glasses.
(2) Application of competitive acquisition
(A) In general
Section 1834(h)(1)(H) of the Social Security Act (42 U.S.C. 1395m(h)(1)(H)), as amended by section 3(b)(3)(A), is amended—
(i)
in the heading, by striking and hearing aids
and inserting hearing aids, and eyeglasses
;
(ii)
in the matter preceding clause (i)—
(I)
by striking or of hearing aids
and inserting of hearing aids
; and
(II)
by inserting or of eyeglasses described in paragraph (2)(E) of such section,
after paragraph (2)(D) of such section,
; and
(iii)
in clause (i), by striking or such hearing aids
and inserting , such hearing aids, or such eyeglasses
.
(B) Conforming amendment
Section 1847(a)(2) of the Social Security Act (42 U.S.C. 1395w–3(a)(2)), as amended by section 3(b)(3)(B)(i), is amended by adding at the end the following new subparagraph:
(F) Eyeglasses
Eyeglasses described in section 1861(s)(8) for which payment would otherwise be made under section 1834(h).
(C) Implementation
Section 1847(a) of the Social Security Act (42 U.S.C. 1395w–3(a)), as amended by section 3(b)(3)(B)(iii), is amended by adding at the end the following new paragraph:
(9) Competition with respect to eyeglasses
Not later than January 1, 2030, the Secretary shall begin the competition with respect to the items and services described in paragraph (2)(F).
(g) Exclusion modifications
Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)), as amended by section 2(e), is amended—
(1)
in paragraph (1)—
(A)
in subparagraph (P), by striking and
at the end;
(B)
in subparagraph (Q), by striking the semicolon at the end and inserting , and
; and
(C)
by adding at the end the following new subparagraph:
(R)
in the case of vision services (as defined in section 1861(ooo)) that are routine eye examinations as described in such section, which are furnished more frequently than once during a 2-year period;; and
(2)
in paragraph (7)—
(A)
by inserting (other than such an examination that is a vision service that is covered under section 1861(s)(2)(LL))
after eye examinations
; and
(B)
by inserting (other than such a procedure that is a vision service that is covered under section 1861(s)(2)(LL))
after refractive state of the eyes
.
(h) Inclusion as excepted medical treatment
Section 1821(b)(5)(A)(iv) of the Social Security Act (42 U.S.C. 1395i–5(b)(5)(A)(iv)), as added by section 2(f) and amended by section 3(d), is amended—
(1)
by striking or hearing aids
and inserting hearing aids
; and
(2)
by inserting , or vision services (as defined in subsection (ooo) of such section)
after subsection (s)(8) of such section
.
(i) Rural Health Clinics and Federally Qualified Health Centers
(1) Clarifying coverage of vision services as physicians' services
Section 1861(aa)(1)(A) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(A)), as amended by section 3(e)(1), is amended by inserting and vision services (as defined in subsection (ooo))
after (as defined in subsection (ll)(3))
.
(2) Temporary payment rates for certain services under the RHC AIR and FQHC PPS
(A) AIR
Section 1833 of the Social Security Act (42 U.S.C. 1395l), as amended by sections 2(g)(2)(A) and 3(e)(3)(A), is amended—
(i)
in subsection (a)(3)(A)—
(I)
by striking or audiology
and inserting , audiology
; and
(II)
by inserting , or vision services (as defined in section 1861(ooo))
after (as defined in section 1861(ll)(3))
; and
(ii)
in subsection (ee)—
(I)
by striking or audiology
and inserting , audiology
; and
(II)
by inserting , or vision services (as defined in section 1861(ooo))
after (as defined in section 1861(ll)(3))
.
(B) PPS
Section 1834(o)(6) of the Social Security Act (42 U.S.C. 1395m(o)(6)), as added by section 2(g)(2)(B) and amended by section 3(e)(3)(B), is amended—
(i)
in the first sentence—
(I)
by striking or audiology
and inserting , audiology
; and
(II)
by inserting , or vision services (as defined in section 1861(ooo))
after (as defined in section 1861(ll)(3))
; and
(ii)
in the second sentence, by striking or such audiology services
and inserting , such audiology services, or such vision services
.
(j) Expediting implementation
The Secretary of Health and Human Services shall implement this section for 2027 and 2028 through program instruction or other forms of program guidance.
(k) Funding
In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2025, out of any money in the Treasury not otherwise appropriated, $500,000,000, to remain available until expended, for purposes of implementing the amendments made by this section during the period beginning on January 1, 2026, and ending on September 30, 2034.
Sec. 5. Phase-in of impact of dental and oral health coverage on part B premiums
Section 1839(a) of the Social Security Act (42 U.S.C. 1395r(a)) is amended—
(1)
in the second sentence of paragraph (1), by striking and (7)
and inserting (7), and (8)
;
(2)
in paragraph (3), by striking The Secretary
and inserting Subject to paragraph (8)(C), the Secretary
; and
(3)
by adding at the end the following:
(8) Special rule for 2026 through 2030
(A) Determination of alternative monthly actuarial rate for each of 2026 through 2030
For each of 2026 through 2030, the Secretary shall, at the same time as and in addition to the determination of the monthly actuarial rate for enrollees age 65 and over determined in each of 2025 through 2029 for the succeeding calendar year according to paragraph (1), determine an alternative monthly actuarial rate for enrollees age 65 and over for the year as described in subparagraph (B).
(B) Alternative monthly actuarial rate described
(i) In general
The alternative monthly actuarial rate described in this subparagraph is—
(I)
for 2026 and 2027, the monthly actuarial rate for enrollees age 65 and over for the year, determined as if the amendments made by section 2 of the Medicare Dental, Hearing, and Vision Expansion Act of 2025 did not apply; and
(II)
for 2028, 2029, and 2030, the monthly actuarial rate for enrollees age 65 and over for the year, determined as if the amendments made by such section 2 did not apply, plus the applicable percent of the amount by which—
(aa)
the monthly actuarial rate for enrollees age 65 and over for the year determined according to paragraph (1); exceeds
(bb)
the monthly actuarial rate for enrollees age 65 and over for the year, determined as if the amendments made by such section 2 did not apply.
(ii) Definition of applicable percent
For purposes of this subparagraph, the term applicable percent means—
(I)
for 2028, 25 percent;
(II)
for 2029, 50 percent; and
(III)
for 2030, 75 percent.
(C) Application to part b premium and other provisions of this part
For each of 2026 through 2030, the Secretary shall use the alternative monthly actuarial rate for enrollees age 65 and over for the year determined under subparagraph (A), in lieu of the monthly actuarial rate for such enrollees for the year determined according to paragraph (1), when determining the monthly premium rate for the year under paragraph (3) and subsection (j), the part B deductible under section 1833(b), and the premium subsidy and monthly adjustment amount under subsection (i).