I 

117TH CONGRESS 

1ST SESSION H. R. 1916 

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 

MARCH 16, 2021 

Ms. ESHOO (for herself, Mr. FERGUSON, Ms. MCCOLLUM, Mrs. AXNE, Ms. 

DEGETTE, Mr. MCEACHIN, Mrs. LURIA, Mr. STANTON, Ms. STEVENS, 

Mr. HUFFMAN, Mr. GOTTHEIMER, Mrs. TRAHAN, Ms. BARRAGA ́N, Mr. 

GRIJALVA, Mr. WITTMAN, Mr. GALLEGO, Mr. CARBAJAL, Ms. WILD, Mr. 

SUOZZI, Mr. DEUTCH, Ms. NORTON, Mr. FITZPATRICK, Ms. BROWNLEY, 

Mrs. HAYES, Mr. TAKANO, Ms. BLUNT ROCHESTER, Mr. HASTINGS, Mr. 

KIM of New Jersey, Mr. PERLMUTTER, Mr. CROW, Miss RICE of New 

York, Mr. STAUBER, Mr. RODNEY DAVIS of Illinois, Mr. PAYNE, Mr. 

RUPPERSBERGER, Ms. TLAIB, Mr. MOULTON, Mr. PASCRELL, Mrs. WATSON COLEMAN, Mrs. BEATTY, Mr. VELA, Mr. COOPER, Ms. UNDERWOOD, 

Mr. TRONE, Mr. YOUNG, Ms. MENG, Ms. PORTER, Ms. SCANLON, Mr. 

RESCHENTHALER, Mr. VAN DREW, Mr. TIMMONS, Ms. CRAIG, Mr. 

NEGUSE, Ms. PINGREE, Mr. LYNCH, Mr. POSEY, Mr. LAMB, Mr. COLE, 

Mr. JOYCE of Pennsylvania, Mr. SIRES, Mr. PALAZZO, Mr. GRAVES of 

Louisiana, Mr. YARMUTH, Mr. BISHOP of Georgia, Mrs. RADEWAGEN, 

Mr. KILDEE, Mr. BUTTERFIELD, Mr. TONKO, Mr. STIVERS, Ms. ROSS, 

Mr. LEVIN of Michigan, Ms. HOULAHAN, Mrs. NAPOLITANO, Mr. 

RASKIN, Mr. MCNERNEY, Mr. MCGOVERN, Mr. MORELLE, Ms. BASS, 

Ms. BONAMICI, Ms. CLARKE of New York, Ms. SALAZAR, Mr. MRVAN, 

Ms. LEE of California, Mr. RUTHERFORD, Ms. SA ́NCHEZ, Mr. CONNOLLY, Mrs. LAWRENCE, Mr. MCKINLEY, Mr. PRICE of North Carolina, 

Mr. GARAMENDI, Ms. VELA ́ZQUEZ, Mr. ADERHOLT, Ms. KELLY of Illinois, Mr. JONES, Mr. PHILLIPS, Ms. OMAR, Mr. ALLEN, Mr. GARBARINO, 

Mr. GOSAR, Mr. LAWSON of Florida, Mr. RUSH, Mr. CARTER of Georgia, 

Mr. BACON, Mr. GROTHMAN, Mr. HARDER of California, Mr. VICENTE

GONZALEZ of Texas, Mr. MANN, Mr. UPTON, Mr. COHEN, Mr. 

CICILLINE, Mr. KHANNA, Mrs. HARTZLER, Ms. BUSH, Mr. BOST, Ms. 

STRICKLAND, Ms. MANNING, Mr. BRENDAN F. BOYLE of Pennsylvania, 

Mr. GUEST, Mr. SIMPSON, Mr. O’HALLERAN, Ms. MOORE of Wisconsin, 

Mr. BABIN, Ms. TITUS, Ms. JOHNSON of Texas, Mr. POCAN, Mr. 

KRISHNAMOORTHI, Mr. SEAN PATRICK MALONEY of New York, Ms. 

DELBENE, Mr. RYAN, Mr. STEWART, Mr. HAGEDORN, Ms. JAYAPAL, Mr. 


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EMMER, and Mr. MOORE of Utah) introduced the following bill; which 

was referred to the Committee on Energy and Commerce, and in addition 

to the Committees on Ways and Means, and Education and Labor, 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. 

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

3 SECTION 1. SHORT TITLE. 

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

5 Smiles Act’’. 

6 SEC. 2. COVERAGE OF CONGENITAL ANOMALY OR BIRTH 

7 DEFECT. 

8 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.— 

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

10 (42 U.S.C. 300gg–111 et seq.) is amended by adding at 

11 the end the following new section: 

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

13 CONGENITAL ANOMALY OR BIRTH DEFECT. 

14 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC15 TIVE TREATMENT.— 


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

2 health insurance issuer offering group or individual 

3 health insurance coverage, shall provide coverage for 

4 outpatient and inpatient items and services related 

5 to the diagnosis and treatment of a congenital 

6 anomaly or birth 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 individual or group health insur20 ance coverage offered by a health insurance 

21 issuer may be subject to coverage limits (such 

22 as medical necessity, pre-authorization, or pre23 certification) and cost-sharing requirements 

24 (such as coinsurance, copayments, and 

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


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1 that are no more restrictive than the predomi2 nant coverage limits and cost-sharing require3 ments, respectively, applied to substantially all 

4 medical and surgical benefits covered by the 

5 plan (or coverage). 

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

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

8 subparagraph (B), the term ‘treatment’ in9 cludes, with respect to a group health plan or 

10 group or individual health insurance coverage 

11 offered by a health insurance issuer, inpatient 

12 and outpatient items and services performed to 

13 improve, repair, or restore bodily function (or 

14 performed to approximate a normal appear15 ance), due to a congenital anomaly or birth de16 fect, and includes treatment to any and all 

17 missing or abnormal body parts (including 

18 teeth, the oral cavity, and their associated 

19 structures) that would otherwise be provided 

20 under the plan or coverage for any other injury 

21 or sickness, including— 

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

23 inpatient and outpatient care, reconstruc24 tive services and procedures, and complica25 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.—A group health plan under this part 

20 shall comply with the notice requirement under section 

21 714(c) of the Employee Retirement Income Security Act 

22 of 1974 with respect to the requirements of this section 

23 as if such section applied to such plan.’’. 

24 (b) ERISA AMENDMENTS.— 


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1 (1) IN GENERAL.—Subpart B of part 7 of sub2 title B of title I of the Employee Retirement Income 

3 Security Act of 1974 is amended by adding at the 

4 end the following: 

5 ‘‘SEC. 726. STANDARDS RELATING TO BENEFITS FOR CON6 GENITAL ANOMALY OR BIRTH DEFECT. 

7 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC8 TIVE TREATMENT.— 

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

10 health insurance issuer offering group health insur11 ance coverage, shall provide coverage for outpatient 

12 and inpatient items and services related to the diag13 nosis and treatment of a congenital anomaly or birth 

14 defect. 

15 ‘‘(2) REQUIREMENTS.— 

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

17 under paragraph (1) shall include any medically 

18 necessary item or service to functionally im19 prove, repair, or restore any body part to 

20 achieve normal body functioning or appearance, 

21 as determined by the treating physician (as de22 fined in section 1861(r) of the Social Security 

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

24 ‘‘(B) FINANCIAL REQUIREMENTS AND

25 TREATMENT REQUIREMENTS.—Any coverage 


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1 provided under paragraph (1) under a group 

2 health plan or group health insurance coverage 

3 offered by a health insurance issuer may be 

4 subject to coverage limits (such as medical ne5 cessity, pre-authorization, or pre-certification) 

6 and cost-sharing requirements (such as coinsur7 ance, copayments, and deductibles), as required 

8 by the plan or issuer, that are no more restric9 tive than the predominant coverage limits and 

10 cost-sharing requirements, respectively, applied 

11 to substantially all medical and surgical benefits 

12 covered by the plan (or coverage). 

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

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

15 subparagraph (B), the term ‘treatment’ in16 cludes, with respect to a group health plan or 

17 group health insurance coverage offered by a 

18 health insurance issuer, inpatient and out19 patient items and services performed to im20 prove, repair, or restore bodily function (or per21 formed to approximate a normal appearance), 

22 due to a congenital anomaly or birth defect, and 

23 includes treatment to any and all missing or ab24 normal body parts (including teeth, the oral 

25 cavity, and their associated structures) that 


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1 would otherwise be provided under the plan or 

2 coverage for any other injury or sickness, in3 cluding— 

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

5 inpatient and outpatient care, reconstruc6 tive services and procedures, and complica7 tions thereof; 

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

9 prosthodontic support from birth until the 

10 medical or surgical treatment of the defect 

11 or anomaly has been completed, including 

12 ongoing or subsequent treatment required 

13 to maintain function or approximate a nor14 mal appearance; 

15 ‘‘(iii) procedures that materially im16 prove, repair, or restore bodily function; 

17 and 

18 ‘‘(iv) procedures for secondary condi19 tions and follow-up treatment associated 

20 with the underlying congenital anomaly or 

21 birth defect. 

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

23 shall not include cosmetic surgery performed to 

24 reshape normal structures of the body to im25 prove appearance or self-esteem. 


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1 ‘‘(b) NOTICE.—A group health plan under this part 

2 shall comply with the notice requirement under section 

3 714(c) with respect to the requirements of this section as 

4 if such section applied to such plan.’’. 

5 (2) TECHNICAL AMENDMENTS.— 

6 (A) Section 732(a) of such Act (29 U.S.C. 

7 1191a(a)) is amended by striking ‘‘section 711’’ 

8 and inserting ‘‘sections 711 and 726’’. 

9 (B) The table of contents in section 1 of 

10 such Act is amended by inserting after the item 

11 relating to section 725 the following new item: 

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

12 (c) INTERNAL REVENUE CODE AMENDMENTS.— 

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

14 100 of the Internal Revenue Code of 1986 is amend15 ed by adding at the end the following: 

16 ‘‘SEC. 9826. STANDARDS RELATING TO BENEFITS FOR CON17 GENITAL ANOMALY OR BIRTH DEFECT. 

18 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC19 TIVE TREATMENT.— 

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

21 provide coverage for outpatient and inpatient items 

22 and services related to the diagnosis and treatment 

23 of a congenital anomaly or birth defect. 

24 ‘‘(2) REQUIREMENTS.— 


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

2 under paragraph (1) shall include any medically 

3 necessary item or service to functionally im4 prove, repair, or restore any body part to 

5 achieve normal body functioning or appearance, 

6 as determined by the treating physician (as de7 fined in section 1861(r) of the Social Security 

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

9 ‘‘(B) FINANCIAL REQUIREMENTS AND

10 TREATMENT REQUIREMENTS.—Any coverage 

11 provided under paragraph (1) under a group 

12 health plan may be subject to coverage limits 

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

14 pre-certification) and cost-sharing requirements 

15 (such as coinsurance, copayments, and 

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

17 no more restrictive than the predominant cov18 erage limits and cost-sharing requirements, re19 spectively, applied to substantially all medical 

20 and surgical benefits covered by the plan. 

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

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

23 subparagraph (B), the term ‘treatment’ in24 cludes, with respect to a group health plan, in25 patient and outpatient items and services perVerDate Sep 11 2014 22:24 May 11, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.IH H1916

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1 formed to improve, repair, or restore bodily 

2 function (or performed to approximate a normal 

3 appearance), due to a congenital anomaly or 

4 birth defect, and includes treatment to any and 

5 all missing or abnormal body parts (including 

6 teeth, the oral cavity, and their associated 

7 structures) that would otherwise be provided 

8 under the plan for any other injury or sickness, 

9 including— 

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

11 inpatient and outpatient care, reconstruc12 tive services and procedures, and complica13 tions thereof; 

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

15 prosthodontic support from birth until the 

16 medical or surgical treatment of the defect 

17 or anomaly has been completed, including 

18 ongoing or subsequent treatment required 

19 to maintain function or approximate a nor20 mal appearance; 

21 ‘‘(iii) procedures that materially im22 prove, repair, or restore bodily function; 

23 and 

24 ‘‘(iv) procedures for secondary condi25 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.—A group health plan under this part 

8 shall comply with the notice requirement under section 

9 714(c) of the Employee Retirement Income Security Act 

10 of 1974 with respect to the requirements of this section 

11 as if such section applied to such plan.’’. 

12 (2) CLERICAL AMENDMENT.—The table of sec13 tions for such subchapter is amended by adding at 

14 the end the following new item: 

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

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

16 or health insurance issuer shall provide the benefits de17 scribed in section 2799A–11 of the Public Health Service 

18 Act (as added by subsection (a)), section 726 of the Em19 ployee Retirement Income Security Act of 1974 (as added 

20 by subsection (b)), and section 9826 of the Internal Rev21 enue Code of 1986 (as added by subsection (c)) under the 

22 terms of such plan or health insurance coverage offered 

23 by such issuer. 


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1 (e) CLARIFYING AMENDMENT REGARDING APPLICA2 TION TO GRANDFATHERED PLANS.—Section 

3 1251(a)(4)(A) of the Patient Protection and Affordable 

4 Care Act (42 U.S.C. 18011(a)(4)(A)), is amended by add5 ing at the end the following: 

6 ‘‘(v) Section 2799A–11 (relating to 

7 standards relating to benefits for con8 genital anomaly or birth defect), as added 

9 by section 2(a) of the Ensuring Lasting 

10 Smiles Act.’’. 

11 (f) EFFECTIVE DATE.—The amendments made by 

12 this section shall apply with respect to group health plans 

13 for plan years beginning on or after January 1, 2022, and 

14 with respect to health insurance coverage offered, sold, 

15 issued, renewed, in effect, or operated in the individual 

16 market on or after such date. 

17 (g) COORDINATED REGULATIONS.—Section 104(1) 

18 of the Health Insurance Portability and Accountability 

19 Act of 1996 is amended by striking ‘‘this subtitle (and 

20 the amendments made by this subtitle and section 401)’’ 

21 and inserting ‘‘the provisions of part 7 of subtitle B of 

22 title I of the Employee Retirement Income Security Act 

23 of 1974, the provisions of parts A, C, and D of title XXVII 


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1 of the Public Health Service Act, and chapter 100 of the 

2 Internal Revenue Code of 1986’’. 

Æ 


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