Ensuring Lasting Smiles Act

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3277 Introduced in House (IH)]

<DOC>

119th CONGRESS
  1st Session
                                H. R. 3277

To provide health insurance benefits for outpatient and inpatient items
  and services related to the diagnosis and treatment of a congenital
                        anomaly or birth defect.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                              May 8, 2025

Mr. Dunn of Florida (for himself, Ms. Schrier, Mr. Aderholt, Mr. Babin,
 Ms. Salazar, Mr. Gosar, Mr. Nehls, Mr. Yakym, Ms. Moore of Wisconsin,
  Mrs. Dingell, Ms. Norton, Ms. Tlaib, Mr. Landsman, Mr. Fields, Ms.
Bonamici, Mr. Mrvan, Mr. Quigley, Mr. Mannion, Mr. Lynch, Ms. Omar, Ms.
 Houlahan, Ms. Tokuda, and Mr. Neguse) introduced the following bill;
  which was referred to the Committee on Energy and Commerce, and in
  addition to the Committees on Education and Workforce, and Ways and
 Means, for a period to be subsequently determined by the Speaker, in
   each case for consideration of such provisions as fall within the
                jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL

To provide health insurance benefits for outpatient and inpatient items
  and services related to the diagnosis and treatment of a congenital
                        anomaly or birth defect.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Ensuring Lasting Smiles Act''.

SEC. 2. COVERAGE OF CONGENITAL ANOMALY OR BIRTH DEFECT.

    (a) Public Health Service Act Amendments.--Part D of title XXVII of
the Public Health Service Act (42 U.S.C. 300gg-111 et seq.) is amended
by adding at the end the following new section:

``SEC. 2799A-11. COVERAGE OF CONGENITAL ANOMALY OR BIRTH DEFECT.

    ``(a) Requirements for Care and Reconstructive Treatment.--
            ``(1) In general.--A group health plan, and a health
        insurance issuer offering group or individual health insurance
        coverage, shall provide coverage for outpatient and inpatient
        items and services related to the diagnosis and treatment of a
        congenital anomaly or birth defect that primarily impacts the
        appearance or function of the eyes, ears, teeth, mouth, or jaw,
        consistent with paragraphs (2) and (3).
            ``(2) Financial requirements.--Any coverage provided under
        paragraph (1) under a group health plan or group or individual
        health insurance coverage may be subject to cost-sharing
        requirements (such as coinsurance, copayments, and
        deductibles), as required by the plan or issuer offering such
        coverage, that are no more restrictive than the predominant
        cost-sharing requirements applied to substantially all other
        medical and surgical benefits covered by the plan or coverage.
            ``(3) Applicable items and services.--
                    ``(A) In general.--Except as provided in
                subparagraph (B), the items and services required under
                paragraph (1) to be covered by a group health plan or
                group or individual health insurance coverage offered
                by a health insurance issuer include--
                            ``(i) any item or service to improve,
                        repair, or restore any body part to achieve
                        normal body functioning or appearance, or
                        performed to approximate a normal appearance,
                        as determined medically necessary by the
                        treating physician (as defined in section
                        1861(r) of the Social Security Act), on account
                        of a congenital anomaly or birth defect that
                        primarily impacts the appearance or function of
                        the eyes, ears, teeth, mouth, or jaw; and
                            ``(ii) any treatment or diagnostic service
                        with respect to any and all missing or abnormal
                        body parts (including teeth, the oral cavity,
                        and their associated structures), as determined
                        medically necessary by the treating physician
                        (as defined in section 1861(r) of the Social
                        Security Act), including--
                                    ``(I) reconstructive services and
                                procedures, and items and services
                                related to any complications arising
                                from such services and procedures;
                                    ``(II) adjunctive dental,
                                orthodontic, or prosthodontic support
                                from birth until the medical or
                                surgical treatment of the defect or
                                anomaly has been completed, including
                                ongoing or subsequent treatment
                                required to maintain function or
                                approximate a normal appearance,
                                notwithstanding any exclusions,
                                limitations, or restrictions under the
                                plan or health insurance coverage on
                                coverage of dental, orthodontic, or
                                prosthodontic items and services
                                arising from other injuries or
                                sicknesses; and
                                    ``(III) items and services related
                                to secondary conditions and follow-up
                                treatment associated with the
                                underlying congenital anomaly or birth
                                defect.
                    ``(B) Exception.--The items and services required
                under this subsection to be covered by a group health
                plan or health insurance issuer offering group or
                individual health insurance coverage shall not include
                cosmetic surgery performed to reshape normal structures
                of the body to improve appearance or self-esteem, if
                such items and services are not furnished as a result
                of a medical determination of a congenital anomaly or
                birth defect.
    ``(b) Notice.--Beginning not later January 1, 2026, a group health
plan or health insurance issuer offering group or individual health
insurance coverage shall provide notice to each participant and
beneficiary under such plan or coverage regarding the coverage required
by this section in any documents describing services, in accordance
with any regulations promulgated by the Secretary.
    ``(c) Definition.--In this section, the term `congenital anomaly or
birth defect' means a structural or functional anomaly that occurs
during intrauterine life, develops prenatally, and may be identified
before birth, at birth, or later in life, and which may--
            ``(1) be caused by genetic or chromosomal disorders,
        embryotoxic or teratogenic environmental factors, nutrient
        deficiency, multifactorial inheritance, or be of an unknown
        cause;
            ``(2) manifest as abnormal anatomical structures;
            ``(3) manifest as physical, sensory, or cognitive
        functional disabilities;
            ``(4) manifest as syndromes, diseases, or other health
        problems; and
            ``(5) manifest as singular anomalies or in combination
        prenatally, at birth, or later in life.''.
    (b) ERISA Amendments.--
            (1) In general.--Subpart B of part 7 of subtitle B of title
        I of the Employee Retirement Income Security Act of 1974 is
        amended by adding at the end the following:

``SEC. 726. COVERAGE OF CONGENITAL ANOMALY OR BIRTH DEFECT.

    ``(a) Requirements for Care and Reconstructive Treatment.--
            ``(1) In general.--A group health plan, and a health
        insurance issuer offering group health insurance coverage,
        shall provide coverage for outpatient and inpatient items and
        services related to the diagnosis and treatment of a congenital
        anomaly or birth defect that primarily impacts the appearance
        or function of the eyes, ears, teeth, mouth, or jaw, consistent
        with paragraphs (2) and (3).
            ``(2) Financial requirements.--Any coverage provided under
        paragraph (1) under a group health plan or group health
        insurance coverage offered by a health insurance issuer may be
        subject to cost-sharing requirements (such as coinsurance,
        copayments, and deductibles), as required by the plan or issuer
        offering such coverage, that are no more restrictive than the
        predominant cost-sharing requirements applied to substantially
        all other medical and surgical benefits covered by the plan or
        coverage.
            ``(3) Applicable items and services.--
                    ``(A) In general.--Except as provided in
                subparagraph (B), the items and services required under
                paragraph (1) to be covered by a group health plan or
                group health insurance coverage offered by a health
                insurance issuer include--
                            ``(i) any item or service to improve,
                        repair, or restore any body part to achieve
                        normal body functioning or appearance, or
                        performed to approximate a normal appearance,
                        as determined medically necessary by the
                        treating physician (as defined in section
                        1861(r) of the Social Security Act), on account
                        of a congenital anomaly or birth defect that
                        primarily impacts the appearance or function of
                        the eyes, ears, teeth, mouth, or jaw; and
                            ``(ii) any treatment or diagnostic service
                        with respect to any and all missing or abnormal
                        body parts (including teeth, the oral cavity,
                        and their associated structures), as determined
                        medically necessary by the treating physician
                        (as defined in section 1861(r) of the Social
                        Security Act), including--
                                    ``(I) reconstructive services and
                                procedures, and items and services
                                related to any complications arising
                                from such services and procedures;
                                    ``(II) adjunctive dental,
                                orthodontic, or prosthodontic support
                                from birth until the medical or
                                surgical treatment of the defect or
                                anomaly has been completed, including
                                ongoing or subsequent treatment
                                required to maintain function or
                                approximate a normal appearance,
                                notwithstanding any exclusions,
                                limitations, or restrictions under the
                                plan or health insurance coverage on
                                coverage of dental, orthodontic, or
                                prosthodontic items and services
                                arising from other injuries or
                                sicknesses; and
                                    ``(III) items and services related
                                to secondary conditions and follow-up
                                treatment associated with the
                                underlying congenital anomaly or birth
                                defect.
                    ``(B) Exception.--The items and services required
                under this subsection to be covered by a group health
                plan or health insurance issuer offering group health
                insurance coverage shall not include cosmetic surgery
                performed to reshape normal structures of the body to
                improve appearance or self-esteem, if such items and
                services are not furnished as a result of a medical
                determination of a congenital anomaly or birth defect.
    ``(b) Notice.--Beginning not later than January 1, 2026, a group
health plan or health insurance issuer offering group health insurance
coverage shall provide notice to each participant and beneficiary under
such plan or coverage regarding the coverage required by this section,
in any documents describing services, in accordance with any
regulations promulgated by the Secretary.
    ``(c) Definition.--In this section, the term `congenital anomaly or
birth defect' means a structural or functional anomaly that occurs
during intrauterine life, develops prenatally, and may be identified
before birth, at birth, or later in life, and which may--
            ``(1) be caused by genetic or chromosomal disorders,
        embryotoxic or teratogenic environmental factors, nutrient
        deficiency, multifactorial inheritance, or be of an unknown
        cause;
            ``(2) manifest as abnormal anatomical structures;
            ``(3) manifest as physical, sensory, or cognitive
        functional disabilities;
            ``(4) manifest as syndromes, diseases, or other health
        problems; and
            ``(5) manifest as singular anomalies or in combination
        prenatally, at birth, or later in life.''.
            (2) Technical amendments.--
                    (A) Section 732(a) of such Act (29 U.S.C. 1191a(a))
                is amended by striking ``section 711'' and inserting
                ``sections 711 and 726''.
                    (B) The table of contents in section 1 of such Act
                is amended by inserting after the item relating to
                section 725 the following new item:

``Sec. 726. Coverage of congenital anomaly or birth defect.''.
    (c) Internal Revenue Code Amendments.--
            (1) In general.--Subchapter B of chapter 100 of the
        Internal Revenue Code of 1986 is amended by adding at the end
        the following:

``SEC. 9826. COVERAGE OF CONGENITAL ANOMALY OR BIRTH DEFECT.

    ``(a) Requirements for Care and Reconstructive Treatment.--
            ``(1) In general.--A group health plan shall provide
        coverage for outpatient and inpatient items and services
        related to the diagnosis and treatment of a congenital anomaly
        or birth defect that primarily impacts the appearance or
        function of the eyes, ears, teeth, mouth, or jaw, consistent
        with paragraphs (2) and (3).
            ``(2) Financial requirements.--Any coverage provided under
        paragraph (1) under a group health plan may be subject to cost-
        sharing requirements (such as coinsurance, copayments, and
        deductibles), as required by the plan, that are no more
        restrictive than the predominant cost-sharing requirements
        applied to substantially all other medical and surgical
        benefits covered by the plan.
            ``(3) Applicable items and services.--
                    ``(A) In general.--Except as provided in
                subparagraph (B), the items and services required under
                paragraph (1) to be covered by a group health plan
                include--
                            ``(i) any item or service to improve,
                        repair, or restore any body part to achieve
                        normal body functioning or appearance, or
                        performed to approximate a normal appearance,
                        as determined medically necessary by the
                        treating physician (as defined in section
                        1861(r) of the Social Security Act), on account
                        of a congenital anomaly or birth defect that
                        primarily impacts the appearance or function of
                        the eyes, ears, teeth, mouth, or jaw; and
                            ``(ii) any treatment or diagnostic service
                        with respect to any and all missing or abnormal
                        body parts (including teeth, the oral cavity,
                        and their associated structures), as determined
                        medically necessary by the treating physician
                        (as defined in section 1861(r) of the Social
                        Security Act), including--
                                    ``(I) reconstructive services and
                                procedures, and items and services
                                related to any complications arising
                                from such services and procedures;
                                    ``(II) adjunctive dental,
                                orthodontic, or prosthodontic support
                                from birth until the medical or
                                surgical treatment of the defect or
                                anomaly has been completed, including
                                ongoing or subsequent treatment
                                required to maintain function or
                                approximate a normal appearance,
                                notwithstanding any exclusions,
                                limitations, or restrictions under the
                                plan on coverage of dental,
                                orthodontic, or prosthodontic items and
                                services arising from other injuries or
                                sicknesses; and
                                    ``(III) items and services related
                                to secondary conditions and follow-up
                                treatment associated with the
                                underlying congenital anomaly or birth
                                defect.
                    ``(B) Exception.--The items and services required
                under this subsection to be covered by a group health
                plan shall not include cosmetic surgery performed to
                reshape normal structures of the body to improve
                appearance or self-esteem, if such items and services
                are not furnished as a result of a medical
                determination of a congenital anomaly or birth defect.
    ``(b) Notice.--Beginning not later January 1, 2026, a group health
plan shall provide notice to each participant and beneficiary under
such plan or coverage regarding the coverage required by this section
in any documents describing services, in accordance with any
regulations promulgated by the Secretary.
    ``(c) Definition.--In this section, the term `congenital anomaly or
birth defect' means a structural or functional anomaly that occurs
during intrauterine life, develops prenatally, and may be identified
before birth, at birth, or later in life, and which may--
            ``(1) be caused by genetic or chromosomal disorders,
        embryotoxic or teratogenic environmental factors, nutrient
        deficiency, multifactorial inheritance, or be of an unknown
        cause;
            ``(2) manifest as abnormal anatomical structures;
            ``(3) manifest as physical, sensory, or cognitive
        functional disabilities;
            ``(4) manifest as syndromes, diseases, or other health
        problems; and
            ``(5) manifest as singular anomalies or in combination
        prenatally, at birth, or later in life.''.
            (2) Clerical amendment.--The table of sections for such
        subchapter is amended by adding at the end the following new
        item:

``Sec. 9826. Coverage of congenital anomaly or birth defect.''.
    (d) Study and Report on Network Adequacy.--The Secretary of Health
and Human Services shall conduct a study, and not later than December
31, 2027, submit a report to Congress, on the matters relating to
access of services for coverage of outpatient and inpatient items and
services related to the diagnosis and treatment of a congenital anomaly
or birth defect that primarily impacts the appearance or function of
the eyes, ears, teeth, mouth, or jaw. Such study and report shall--
            (1) evaluate the sufficiency and accessibility of networks
        of providers that perform services related to the diagnosis and
        treatment of such congenital anomalies and birth defects under
        group health plans and group and individual health insurance
        coverage (as such terms are defined in section 2791 of the
        Public Health Service Act (42 U.S.C. 300gg-91)); and
            (2) assess any change in out-of-pocket costs for patients,
        by procedure type, resulting from the coverage requirements
        under sections 2799A-11 of the Public Health Service Act, 726
        of the Employee Retirement Income Security Act of 1974, and
        9826 of the Internal Revenue Code of 1986, as added by this
        section, and any change in the overall procedure cost for such
        services.
    (e) Effective Date.--The amendments made by subsections (a), (b),
and (c) shall apply with respect to plan years beginning on or after
January 1, 2026.
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