Ensuring Lasting Smiles Act
This bill requires private health insurance plans to cover diagnosis and treatment services for congenital anomalies and birth defects, such as reconstructive services and prosthetics. Coverage must include services that functionally improve, repair, or restore any body part that is medically necessary for normal bodily functions or appearance, as determined by the treating physician.
[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 560 Introduced in Senate (IS)]
<DOC>
116th CONGRESS
1st Session
S. 560
To amend the Public Health Service Act, the Employee Retirement Income
Security Act of 1974, and the Internal Revenue Code of 1986 to require
that group and individual health insurance coverage and group health
plans provide coverage for treatment of a congenital anomaly or birth
defect.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
February 26, 2019
Ms. Baldwin (for herself, Ms. Ernst, Ms. Murkowski, and Mr. Brown)
introduced the following bill; which was read twice and referred to the
Committee on Health, Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To amend the Public Health Service Act, the Employee Retirement Income
Security Act of 1974, and the Internal Revenue Code of 1986 to require
that group and individual health insurance coverage and group health
plans provide coverage for 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.--
(1) In general.--Title XXVII of the Public Health Service
Act is amended by inserting after section 2729 (42 U.S.C.
300gg-19b), the following:
``SEC. 2730. STANDARDS RELATING TO BENEFITS FOR 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
services related to the diagnosis and treatment of a congenital
anomaly or birth defect.
``(2) Requirements.--Coverage provided under paragraph (1)
shall include any service to functionally improve, repair, or
restore any body part that is medically necessary to achieve
normal body functioning or appearance, as determined by the
treating physician (as defined in section 1861 of the Social
Security Act). Any coverage provided under such paragraph may
be subject to coverage limits, such as pre-authorization or
pre-certification, as required by the plan or issuer that are
no more restrictive than the predominant treatment limitations
applied to substantially all medical and surgical benefits
covered by the plan (or coverage).
``(3) Treatment defined.--
``(A) In general.--Except as provided in
subparagraph (B), in this section, the term `treatment'
includes patient and outpatient care and services
performed to improve or restore body function (or
performed to approximate a normal appearance), due to
congenital anomaly or birth defect and shall include
treatment to any and all missing or abnormal body
parts, (including teeth, the oral cavity, and their
associated structures) that would otherwise be provided
under the plan or coverage for any other injury and
sickness, including--
``(i) inpatient and outpatient care,
reconstructive services and procedures, and
complications thereof, including prosthetics
and appliances;
``(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;
``(iii) procedures that do not materially
restore or improve the function of the body
part being treated; and
``(iv) procedures for secondary conditions
and follow-up treatment.
``(B) Exception.--The term `treatment' shall not
include cosmetic surgery performed to reshape normal
structures of the body to improve appearance or self-
esteem.
``(b) Notice.--A group health plan under this part shall comply
with the notice requirement under section 714(b) of the Employee
Retirement Income Security Act of 1974 with respect to the requirements
of this section as if such section applied to such plan.''.
(2) Technical amendments.--
(A) Section 2724(c) of the Public Health Service
Act (42 U.S.C. 300gg-23(c)) is amended by striking
``section 2704'' and inserting ``sections 2725 and
2730''.
(B) Section 2762(b)(2) of the Public Health Service
Act (42 U.S.C. 300gg-62(b)(2)) is amended by striking
``section 2751'' and inserting ``sections 2730 and
2751''.
(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. 716. STANDARDS RELATING TO BENEFITS FOR CONGENITAL ANOMALY OR
BIRTH DEFECT.
``(a) Requirements for 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
services related to the diagnosis and treatment of a congenital
anomaly or birth defect.
``(2) Requirements.--Coverage provided under paragraph (1)
shall include any service to functionally improve, repair, or
restore any body part that is medically necessary to achieve
normal body functioning or appearance, as determined by the
treating physician (as defined in section 1861 of the Social
Security Act). Any coverage provided under such paragraph may
be subject to coverage limits, such as pre-authorization or
pre-certification, as required by the plan or issuer that are
no more restrictive than the predominant treatment limitations
applied to substantially all medical and surgical benefits
covered by the plan (or coverage).
``(3) Treatment defined.--
``(A) In general.--Except as provided in
subparagraph (B), in this section, the term `treatment'
includes patient and outpatient care and services
performed to improve or restore body function (or
performed to approximate a normal appearance), due to
congenital anomaly or birth defect and shall include
treatment to any and all missing or abnormal body
parts, (including teeth, the oral cavity, and their
associated structures) that would otherwise be provided
under the plan or coverage for any other injury and
sickness, including--
``(i) inpatient and outpatient care,
reconstructive services and procedures, and
complications thereof, including prosthetics
and appliances;
``(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;
``(iii) procedures that do not materially
restore or improve the function of the body
part being treated; and
``(iv) procedures for secondary conditions
and follow-up treatment.
``(B) Exception.--The term `treatment' shall not
include cosmetic surgery performed to reshape normal
structures of the body to improve appearance or self-
esteem.
``(b) Notice Under Group Health Plan.--The imposition of the
requirements of this section shall be treated as a material
modification in the terms of the plan described in the last sentence of
section 102(a), for purposes of assuring notice of such requirements
under the plan, except that the summary description required to be
provided under the fourth sentence of section 104(b)(1) with respect to
such modification shall be provided by not later than 60 days after the
first day of the first plan year in which such requirements apply.''.
(2) Technical amendments.--
(A) Section 731(c) of such Act (29 U.S.C. 1191(c))
is amended by striking ``section 711'' and inserting
``sections 711 and 716''.
(B) Section 732(a) of such Act (29 U.S.C. 1191a(a))
is amended by striking ``section 711'' and inserting
``sections 711 and 716''.
(C) The table of contents in section 1 of such Act
is amended by inserting after the item relating to
section 714 the following new items:
Sec. 715. Additional market reforms.
Sec. 716. Standards relating to benefits for 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, as amended by subsection (f) of
the section 1563 (relating to conforming amendments) of Public
Law 111-148, is amended by adding at the end the following:
``SEC. 9816. STANDARDS RELATING TO BENEFITS FOR CONGENITAL ANOMALY OR
BIRTH DEFECT.
``(a) Requirements for Reconstructive Treatment.--A group health
plan, and a health insurance issuer offering group or individual health
insurance coverage, shall provide coverage for outpatient and inpatient
services related to the diagnosis and treatment of a congenital anomaly
or birth defect.
``(b) Requirements.--Coverage provided under subsection (a) shall
include any service to functionally improve, repair, or restore any
body part that is medically necessary to achieve normal body
functioning or appearance, as determined by the treating physician (as
defined in section 1861 of the Social Security Act). Any coverage
provided under such subsection may be subject to coverage limits, such
as pre-authorization or pre-certification, as required by the plan or
issuer that are no more restrictive than the predominant treatment
limitations applied to substantially all medical and surgical benefits
covered by the plan (or coverage).
``(c) Treatment Defined.--
``(1) In general.--Except as provided in paragraph (2), in
this section, the term `treatment' includes patient and
outpatient care and services performed to improve or restore
body function (or performed to approximate a normal
appearance), due to congenital anomaly or birth defect and
shall include treatment to any and all missing or abnormal body
parts, (including teeth, the oral cavity, and their associated
structures) that would otherwise be provided under the plan or
coverage for any other injury and sickness, including--
``(A) inpatient and outpatient care, reconstructive
services and procedures, and complications thereof,
including prosthetics and appliances;
``(B) 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;
``(C) procedures that do not materially restore or
improve the function of the body part being treated;
and
``(D) procedures for secondary conditions and
follow-up treatment.
``(2) Exception.--The term `treatment' shall not include
cosmetic surgery performed to reshape normal structures of the
body to improve appearance or self-esteem.''.
(2) Clerical amendment.--The table of sections for such
subchapter is amended by adding at the end the following new
items:
``Sec. 9815. Additional market reforms.
``Sec. 9816. Standards relating to benefits for congenital anomaly or
birth defect.''.
(d) Clarifying Amendment Regarding Application to Grandfathered
Plans.--Section 1251(a)(4)(A) of the Patient Protection and Affordable
Care Act (42 U.S.C. 18011(a)(4)(A)), is amended by adding at the end
the following:
``(v) Section 2730 (relating to standards
relating to benefits for congenital anomaly or
birth defect), as added by section 2(a) of the
Ensuring Lasting Smiles Act.''.
(e) Effective Date.--The amendments made by this section shall
apply with respect to group health plans for plan years beginning on or
after January 1, 2020, and with respect to health insurance coverage
offered, sold, issued, renewed, in effect, or operated in the
individual market on or after such date.
(f) Coordinated Regulations.--Section 104(1) of the Health
Insurance Portability and Accountability Act of 1996 is amended by
striking ``this subtitle (and the amendments made by this subtitle and
section 401)'' and inserting ``the provisions of part 7 of subtitle B
of title I of the Employee Retirement Income Security Act of 1974, the
provisions of parts A and C of title XXVII of the Public Health Service
Act, and chapter 100 of the Internal Revenue Code of 1986''.
<all>
Introduced in Senate
Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
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