No official summary available for this bill.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 1677 Introduced in Senate (IS)]
<DOC>
119th CONGRESS
1st Session
S. 1677
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 SENATE OF THE UNITED STATES
May 8, 2025
Ms. Baldwin (for herself, Ms. Ernst, Ms. Klobuchar, Ms. Murkowski, Mr.
Lujan, Mr. Tillis, Mr. King, Mr. Marshall, Mr. Reed, Mr. Grassley, Mr.
Blumenthal, Mr. Booker, and Mr. Merkley) introduced the following bill;
which was read twice and referred to the Committee on Health,
Education, Labor, and Pensions
_______________________________________________________________________
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.
<all>
Introduced in Senate
Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
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