IIB 

117TH CONGRESS 

2D SESSION H. R. 1916 

IN THE SENATE OF THE UNITED STATES 

APRIL 5, 2022 

Received; read twice and referred to the Committee on Health, Education, 

Labor, and Pensions 

AN ACT 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Ensuring Lasting 

3 Smiles Act’’. 

4 SEC. 2. COVERAGE OF CONGENITAL ANOMALY OR BIRTH 

5 DEFECT. 

6 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.— 

7 Part D of title XXVII of the Public Health Service Act 

8 (42 U.S.C. 300gg–111 et seq.) is amended by adding at 

9 the end the following new section: 

10 ‘‘SEC. 2799A–11. STANDARDS RELATING TO BENEFITS FOR 

11 CONGENITAL ANOMALY OR BIRTH DEFECT. 

12 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC13 TIVE TREATMENT.— 

14 ‘‘(1) IN GENERAL.—A group health plan, and a 

15 health insurance issuer offering group or individual 

16 health insurance coverage, shall provide coverage for 

17 outpatient and inpatient items and services related 

18 to the diagnosis and treatment of a congenital 

19 anomaly or birth defect. 

20 ‘‘(2) REQUIREMENTS.— 

21 ‘‘(A) IN GENERAL.—Coverage provided 

22 under paragraph (1) shall include any medically 

23 necessary item or service to functionally im24 prove, repair, or restore any body part to 

25 achieve normal body functioning or appearance, 

26 as determined by the treating physician (as deVerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916

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1 fined in section 1861(r) of the Social Security 

2 Act), due to congenital anomaly or birth defect. 

3 ‘‘(B) FINANCIAL REQUIREMENTS AND

4 TREATMENT REQUIREMENTS.—Any coverage 

5 provided under paragraph (1) under a group 

6 health plan or individual or group health insur7 ance coverage offered by a health insurance 

8 issuer may be subject to coverage limits (such 

9 as medical necessity, pre-authorization, or pre10 certification) and cost-sharing requirements 

11 (such as coinsurance, copayments, and 

12 deductibles), as required by the plan or issuer, 

13 that are no more restrictive than the predomi14 nant coverage limits and cost-sharing require15 ments, respectively, applied to substantially all 

16 medical and surgical benefits covered by the 

17 plan (or coverage). 

18 ‘‘(3) TREATMENT DEFINED.—In this section: 

19 ‘‘(A) IN GENERAL.—Except as provided in 

20 subparagraph (B), the term ‘treatment’ in21 cludes, with respect to a group health plan or 

22 group or individual health insurance coverage 

23 offered by a health insurance issuer, inpatient 

24 and outpatient items and services performed to 

25 improve, repair, or restore bodily function (or 


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1 performed to approximate a normal appear2 ance), due to a congenital anomaly or birth de3 fect, and includes treatment to any and all 

4 missing or abnormal body parts (including 

5 teeth, the oral cavity, and their associated 

6 structures) that would otherwise be provided 

7 under the plan or coverage for any other injury 

8 or sickness, including— 

9 ‘‘(i) any items or services, including 

10 inpatient and outpatient care, reconstruc11 tive services and procedures, and complica12 tions thereof; 

13 ‘‘(ii) adjunctive dental, orthodontic, or 

14 prosthodontic support from birth until the 

15 medical or surgical treatment of the defect 

16 or anomaly has been completed, including 

17 ongoing or subsequent treatment required 

18 to maintain function or approximate a nor19 mal appearance; 

20 ‘‘(iii) procedures that materially im21 prove, repair, or restore bodily function; 

22 and 

23 ‘‘(iv) procedures for secondary condi24 tions and follow-up treatment associated 


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1 with the underlying congenital anomaly or 

2 birth defect. 

3 ‘‘(B) EXCEPTION.—The term ‘treatment’ 

4 shall not include cosmetic surgery performed to 

5 reshape normal structures of the body to im6 prove appearance or self-esteem. 

7 ‘‘(b) NOTICE.—Not later than one year after the date 

8 of the enactment of this section and annually thereafter, 

9 a group health plan, and a health insurance issuer offering 

10 group or individual health insurance coverage, shall, in ac11 cordance with regulations or guidance issued by the Sec12 retary, provide to each enrollee under such plan or cov13 erage a written description of the terms of this section. 

14 Such description shall be in language which is understand15 able to the typical enrollee.’’. 

16 (b) ERISA AMENDMENTS.— 

17 (1) IN GENERAL.—Subpart B of part 7 of sub18 title B of title I of the Employee Retirement Income 

19 Security Act of 1974 is amended by adding at the 

20 end the following: 

21 ‘‘SEC. 726. STANDARDS RELATING TO BENEFITS FOR CON22 GENITAL ANOMALY OR BIRTH DEFECT. 

23 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC24 TIVE TREATMENT.— 


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1 ‘‘(1) IN GENERAL.—A group health plan, and a 

2 health insurance issuer offering group health insur3 ance coverage, shall provide coverage for outpatient 

4 and inpatient items and services related to the diag5 nosis and treatment of a congenital anomaly or birth 

6 defect. 

7 ‘‘(2) REQUIREMENTS.— 

8 ‘‘(A) IN GENERAL.—Coverage provided 

9 under paragraph (1) shall include any medically 

10 necessary item or service to functionally im11 prove, repair, or restore any body part to 

12 achieve normal body functioning or appearance, 

13 as determined by the treating physician (as de14 fined in section 1861(r) of the Social Security 

15 Act), due to congenital anomaly or birth defect. 

16 ‘‘(B) FINANCIAL REQUIREMENTS AND

17 TREATMENT REQUIREMENTS.—Any coverage 

18 provided under paragraph (1) under a group 

19 health plan or group health insurance coverage 

20 offered by a health insurance issuer may be 

21 subject to coverage limits (such as medical ne22 cessity, pre-authorization, or pre-certification) 

23 and cost-sharing requirements (such as coinsur24 ance, copayments, and deductibles), as required 

25 by the plan or issuer, that are no more restricVerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916

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1 tive than the predominant coverage limits and 

2 cost-sharing requirements, respectively, applied 

3 to substantially all medical and surgical benefits 

4 covered by the plan (or coverage). 

5 ‘‘(3) TREATMENT DEFINED.—In this section: 

6 ‘‘(A) IN GENERAL.—Except as provided in 

7 subparagraph (B), the term ‘treatment’ in8 cludes, with respect to a group health plan or 

9 group health insurance coverage offered by a 

10 health insurance issuer, inpatient and out11 patient items and services performed to im12 prove, repair, or restore bodily function (or per13 formed to approximate a normal appearance), 

14 due to a congenital anomaly or birth defect, and 

15 includes treatment to any and all missing or ab16 normal body parts (including teeth, the oral 

17 cavity, and their associated structures) that 

18 would otherwise be provided under the plan or 

19 coverage for any other injury or sickness, in20 cluding— 

21 ‘‘(i) any items or services, including 

22 inpatient and outpatient care, reconstruc23 tive services and procedures, and complica24 tions thereof; 


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1 ‘‘(ii) adjunctive dental, orthodontic, or 

2 prosthodontic support from birth until the 

3 medical or surgical treatment of the defect 

4 or anomaly has been completed, including 

5 ongoing or subsequent treatment required 

6 to maintain function or approximate a nor7 mal appearance; 

8 ‘‘(iii) procedures that materially im9 prove, repair, or restore bodily function; 

10 and 

11 ‘‘(iv) procedures for secondary condi12 tions and follow-up treatment associated 

13 with the underlying congenital anomaly or 

14 birth defect. 

15 ‘‘(B) EXCEPTION.—The term ‘treatment’ 

16 shall not include cosmetic surgery performed to 

17 reshape normal structures of the body to im18 prove appearance or self-esteem. 

19 ‘‘(b) NOTICE.—Not later than one year after the date 

20 of the enactment of this section and annually thereafter, 

21 a group health plan, and a health insurance issuer offering 

22 group health insurance coverage, shall, in accordance with 

23 regulations or guidance issued by the Secretary, provide 

24 to each participant or beneficiary under such plan or cov25 erage a written description of the terms of this section. 


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1 Such description shall be in language which is understand2 able to the typical participant or beneficiary.’’. 

3 (2) TECHNICAL AMENDMENT.—The table of 

4 contents in section 1 of such Act is amended by in5 serting after the item relating to section 725 the fol6 lowing new item: 

‘‘Sec. 726. Standards relating to benefits for congential anomaly or birth defect.’’. 

7 (c) INTERNAL REVENUE CODE AMENDMENTS.— 

8 (1) IN GENERAL.—Subchapter B of chapter 

9 100 of the Internal Revenue Code of 1986 is amend10 ed by adding at the end the following: 

11 ‘‘SEC. 9826. STANDARDS RELATING TO BENEFITS FOR CON12 GENITAL ANOMALY OR BIRTH DEFECT. 

13 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC14 TIVE TREATMENT.— 

15 ‘‘(1) IN GENERAL.—A group health plan shall 

16 provide coverage for outpatient and inpatient items 

17 and services related to the diagnosis and treatment 

18 of a congenital anomaly or birth defect. 

19 ‘‘(2) REQUIREMENTS.— 

20 ‘‘(A) IN GENERAL.—Coverage provided 

21 under paragraph (1) shall include any medically 

22 necessary item or service to functionally im23 prove, repair, or restore any body part to 

24 achieve normal body functioning or appearance, 


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1 as determined by the treating physician (as de2 fined in section 1861(r) of the Social Security 

3 Act), due to congenital anomaly or birth defect. 

4 ‘‘(B) FINANCIAL REQUIREMENTS AND

5 TREATMENT REQUIREMENTS.—Any coverage 

6 provided under paragraph (1) under a group 

7 health plan may be subject to coverage limits 

8 (such as medical necessity, pre-authorization, or 

9 pre-certification) and cost-sharing requirements 

10 (such as coinsurance, copayments, and 

11 deductibles), as required by the plan, that are 

12 no more restrictive than the predominant cov13 erage limits and cost-sharing requirements, re14 spectively, applied to substantially all medical 

15 and surgical benefits covered by the plan. 

16 ‘‘(3) TREATMENT DEFINED.—In this section: 

17 ‘‘(A) IN GENERAL.—Except as provided in 

18 subparagraph (B), the term ‘treatment’ in19 cludes, with respect to a group health plan, in20 patient and outpatient items and services per21 formed to improve, repair, or restore bodily 

22 function (or performed to approximate a normal 

23 appearance), due to a congenital anomaly or 

24 birth defect, and includes treatment to any and 

25 all missing or abnormal body parts (including 


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1 teeth, the oral cavity, and their associated 

2 structures) that would otherwise be provided 

3 under the plan for any other injury or sickness, 

4 including— 

5 ‘‘(i) any items or services, including 

6 inpatient and outpatient care, reconstruc7 tive services and procedures, and complica8 tions thereof; 

9 ‘‘(ii) adjunctive dental, orthodontic, or 

10 prosthodontic support from birth until the 

11 medical or surgical treatment of the defect 

12 or anomaly has been completed, including 

13 ongoing or subsequent treatment required 

14 to maintain function or approximate a nor15 mal appearance; 

16 ‘‘(iii) procedures that materially im17 prove, repair, or restore bodily function; 

18 and 

19 ‘‘(iv) procedures for secondary condi20 tions and follow-up treatment associated 

21 with the underlying congenital anomaly or 

22 birth defect. 

23 ‘‘(B) EXCEPTION.—The term ‘treatment’ 

24 shall not include cosmetic surgery performed to 


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1 reshape normal structures of the body to im2 prove appearance or self-esteem. 

3 ‘‘(b) NOTICE.—Not later than one year after the date 

4 of the enactment of this section and annually thereafter, 

5 a group health plan shall, in accordance with regulations 

6 or guidance issued by the Secretary, provide to each en7 rollee under such plan a written description of the terms 

8 of this section. Such description shall be in language which 

9 is understandable to the typical enrollee.’’. 

10 (2) CLERICAL AMENDMENT.—The table of sec11 tions for such subchapter is amended by adding at 

12 the end the following new item: 

‘‘Sec. 9826. Standards relating to benefits for congenital anomaly or birth defect.’’. 

13 (d) RULE OF CONSTRUCTION.—A group health plan 

14 or health insurance issuer shall provide the benefits de15 scribed in section 2799A–11 of the Public Health Service 

16 Act (as added by subsection (a)), section 726 of the Em17 ployee Retirement Income Security Act of 1974 (as added 

18 by subsection (b)), and section 9826 of the Internal Rev19 enue Code of 1986 (as added by subsection (c)) under the 

20 terms of such plan or health insurance coverage offered 

21 by such issuer. 

22 (e) EFFECTIVE DATE.—The amendments made by 

23 this section shall apply with respect to plan years begin24 ning on or after January 1, 2024. 


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1 SEC. 3. DETERMINATION OF BUDGETARY EFFECTS. 

2 The budgetary effects of this Act, for the purpose of 

3 complying with the Statutory Pay-As-You-Go Act of 2010, 

4 shall be determined by reference to the latest statement 

5 titled ‘‘Budgetary Effects of PAYGO Legislation’’ for this 

6 Act, submitted for printing in the Congressional Record 

7 by the Chairman of the House Budget Committee, pro8 vided that such statement has been submitted prior to the 

9 vote on passage. 

Passed the House of Representatives April 4, 2022. 

Attest: CHERYL L. JOHNSON, 

Clerk. 


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