I 

116TH CONGRESS 

1ST SESSION H. R. 1379 

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 HOUSE OF REPRESENTATIVES 

FEBRUARY 26, 2019 

Mr. PETERSON (for himself, Mr. RIGGLEMAN, Mrs. AXNE, Miss RICE of New 

York, Mr. SIMPSON, Mr. VISCLOSKY, Mr. RODNEY DAVIS of Illinois, and 

Mr. STIVERS) 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 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. 

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 (1) IN GENERAL.—Title XXVII of the Public 

8 Health Service Act is amended by inserting after 

9 section 2729 (42 U.S.C. 300gg–28), the following: 

10 ‘‘SEC. 2730. STANDARDS RELATING TO BENEFITS FOR CON11 GENITAL 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 services related to the diag18 nosis and treatment of a congenital anomaly or birth 

19 defect. 

20 ‘‘(2) REQUIREMENTS.—Coverage provided 

21 under paragraph (1) shall include any service to 

22 functionally improve, repair, or restore any body 

23 part that is medically necessary to achieve normal 

24 body functioning or appearance, as determined by 

25 the treating physician (as defined in section 1861 of 

26 the Social Security Act). Any coverage provided 


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1 under such paragraph may be subject to coverage 

2 limits, such as pre-authorization or pre-certification, 

3 as required by the plan or issuer that are no more 

4 restrictive than the predominant treatment limita5 tions applied to substantially all medical and sur6 gical benefits covered by the plan (or coverage). 

7 ‘‘(3) TREATMENT DEFINED.— 

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

9 subparagraph (B), in this section, the term 

10 ‘treatment’ includes patient and outpatient care 

11 and services performed to improve or restore 

12 body function (or performed to approximate a 

13 normal appearance), due to congenital anomaly 

14 or birth defect and shall include treatment to 

15 any and all missing or abnormal body parts, 

16 (including teeth, the oral cavity, and their asso17 ciated structures) that would otherwise be pro18 vided under the plan or coverage for any other 

19 injury and sickness, including— 

20 ‘‘(i) inpatient and outpatient care, re21 constructive services and procedures, and 

22 complications thereof, including prosthetics 

23 and appliances; 

24 ‘‘(ii) adjunctive dental, orthodontic or 

25 prosthodontic support from birth until the 


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1 medical or surgical treatment of the defect 

2 or anomaly has been completed, including 

3 ongoing or subsequent treatment required 

4 to maintain function or approximate a nor5 mal appearance; 

6 ‘‘(iii) procedures that do not materi7 ally restore or improve the function of the 

8 body part being treated; and 

9 ‘‘(iv) procedures for secondary condi10 tions and follow-up treatment. 

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

12 shall not include cosmetic surgery performed to 

13 reshape normal structures of the body to im14 prove appearance or self-esteem. 

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

16 shall comply with the notice requirement under section 

17 714(b) of the Employee Retirement Income Security Act 

18 of 1974 with respect to the requirements of this section 

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

20 (2) TECHNICAL AMENDMENTS.— 

21 (A) Section 2724(c) of the Public Health 

22 Service Act (42 U.S.C. 300gg–23(c)) is amend23 ed by striking ‘‘section 2704’’ and inserting 

24 ‘‘sections 2725 and 2729’’. 


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1 (B) Section 2762(b)(2) of the Public 

2 Health Service Act (42 U.S.C. 300gg–62(b)(2)) 

3 is amended by striking ‘‘section 2751’’ and in4 serting ‘‘sections 2729 and 2751’’. 

5 (b) ERISA AMENDMENTS.— 

6 (1) IN GENERAL.—Subpart B of part 7 of sub7 title B of title I of the Employee Retirement Income 

8 Security Act of 1974 is amended by adding at the 

9 end the following: 

10 ‘‘SEC. 716. STANDARDS RELATING TO BENEFITS FOR CON11 GENITAL ANOMALY OR BIRTH DEFECT. 

12 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE TREAT13 MENT.— 

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 services related to the diag18 nosis and treatment of a congenital anomaly or birth 

19 defect. 

20 ‘‘(2) REQUIREMENTS.—Coverage provided 

21 under paragraph (1) shall include any service to 

22 functionally improve, repair, or restore any body 

23 part that is medically necessary to achieve normal 

24 body functioning or appearance, as determined by 

25 the treating physician (as defined in section 1861 of 


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1 the Social Security Act). Any coverage provided 

2 under such paragraph may be subject to coverage 

3 limits, such as pre-authorization or pre-certification, 

4 as required by the plan or issuer that are no more 

5 restrictive than the predominant treatment limita6 tions applied to substantially all medical and sur7 gical benefits covered by the plan (or coverage). 

8 ‘‘(3) TREATMENT DEFINED.— 

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

10 subparagraph (B), in this section, the term 

11 ‘treatment’ includes patient and outpatient care 

12 and services performed to improve or restore 

13 body function (or performed to approximate a 

14 normal appearance), due to congenital anomaly 

15 or birth defect and shall include treatment to 

16 any and all missing or abnormal body parts, 

17 (including teeth, the oral cavity, and their asso18 ciated structures) that would otherwise be pro19 vided under the plan or coverage for any other 

20 injury and sickness, including— 

21 ‘‘(i) inpatient and outpatient care, re22 constructive services and procedures, and 

23 complications thereof, including prosthetics 

24 and appliances; 


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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 do not materi9 ally restore or improve the function of the 

10 body part being treated; and 

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

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

14 shall not include cosmetic surgery performed to 

15 reshape normal structures of the body to im16 prove appearance or self-esteem. 

17 ‘‘(b) NOTICE UNDER GROUP HEALTH PLAN.—The 

18 imposition of the requirements of this section shall be 

19 treated as a material modification in the terms of the plan 

20 described in the last sentence of section 102(a), for pur21 poses of assuring notice of such requirements under the 

22 plan, except that the summary description required to be 

23 provided under the fourth sentence of section 104(b)(1) 

24 with respect to such modification shall be provided by not 


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1 later than 60 days after the first day of the first plan 

2 year in which such requirements apply.’’. 

3 (2) TECHNICAL AMENDMENTS.— 

4 (A) Section 731(c) of such Act (29 U.S.C. 

5 1191(c)) is amended by striking ‘‘section 711’’ 

6 and inserting ‘‘sections 711 and 716’’. 

7 (B) Section 732(a) of such Act (29 U.S.C. 

8 1191a(a)) is amended by striking ‘‘section 711’’ 

9 and inserting ‘‘sections 711 and 716’’. 

10 (C) The table of contents in section 1 of 

11 such Act is amended by inserting after the item 

12 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.’’. 

13 (c) INTERNAL REVENUE CODE AMENDMENTS.— 

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

15 100 of the Internal Revenue Code of 1986 is amend16 ed by adding at the end the following: 

17 ‘‘SEC. 9816. STANDARDS RELATING TO BENEFITS FOR CON18 GENITAL ANOMALY OR BIRTH DEFECT. 

19 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE TREAT20 MENT.—A group health plan, and a health insurance 

21 issuer offering group or individual health insurance cov22 erage, shall provide coverage for outpatient and inpatient 

23 services related to the diagnosis and treatment of a con24 genital anomaly or birth defect. 


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1 ‘‘(b) REQUIREMENTS.—Coverage provided under 

2 subsection (a) shall include any service to functionally im3 prove, repair, or restore any body part that is medically 

4 necessary to achieve normal body functioning or appear5 ance, as determined by the treating physician (as defined 

6 in section 1861 of the Social Security Act). Any coverage 

7 provided under such subsection may be subject to coverage 

8 limits, such as pre-authorization or pre-certification, as re9 quired by the plan or issuer that are no more restrictive 

10 than the predominant treatment limitations applied to 

11 substantially all medical and surgical benefits covered by 

12 the plan (or coverage). 

13 ‘‘(c) TREATMENT DEFINED.— 

14 ‘‘(1) IN GENERAL.—Except as provided in para15 graph (2), in this section, the term ‘treatment’ in16 cludes patient and outpatient care and services per17 formed to improve or restore body function (or per18 formed to approximate a normal appearance), due to 

19 congenital anomaly or birth defect and shall include 

20 treatment to any and all missing or abnormal body 

21 parts, (including teeth, the oral cavity, and their as22 sociated structures) that would otherwise be pro23 vided under the plan or coverage for any other in24 jury and sickness, including— 


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1 ‘‘(A) inpatient and outpatient care, recon2 structive services and procedures, and complica3 tions thereof, including prosthetics and appli4 ances; 

5 ‘‘(B) adjunctive dental, orthodontic or 

6 prosthodontic support from birth until the med7 ical or surgical treatment of the defect or 

8 anomaly has been completed, including ongoing 

9 or subsequent treatment required to maintain 

10 function or approximate a normal appearance; 

11 ‘‘(C) procedures that do not materially re12 store or improve the function of the body part 

13 being treated; and 

14 ‘‘(D) procedures for secondary conditions 

15 and follow-up treatment. 

16 ‘‘(2) EXCEPTION.—The term ‘treatment’ shall 

17 not include cosmetic surgery performed to reshape 

18 normal structures of the body to improve appearance 

19 or self-esteem.’’. 

20 (2) CLERICAL AMENDMENT.—The table of sec21 tions for such subchapter is amended by adding at 

22 the end the following new items: 

‘‘Sec. 9815. Additional market reforms. 

‘‘Sec. 9816. Standards relating to benefits for congenital anomaly or birth defect.’’. 

23 (d) CLARIFYING AMENDMENT REGARDING APPLICA24 TION TO GRANDFATHERED PLANS.—Section 


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1 1251(a)(4)(A) of the Patient Protection and Affordable 

2 Care Act (42 U.S.C. 18011(a)(4)(A)), is amended by add3 ing at the end the following: 

4 ‘‘(v) Section 2729 (relating to stand5 ards relating to benefits for congenital 

6 anomaly or birth defect), as added by sec7 tion 2(a) of the Ensuring Lasting Smiles 

8 Act.’’. 

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

10 this section shall apply with respect to group health plans 

11 for plan years beginning on or after January 1, 2020, and 

12 with respect to health insurance coverage offered, sold, 

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

14 market on or after such date. 

15 (f) COORDINATED REGULATIONS.—Section 104(1) of 

16 the Health Insurance Portability and Accountability Act 

17 of 1996 is amended by striking ‘‘this subtitle (and the 

18 amendments made by this subtitle and section 401)’’ and 

19 inserting ‘‘the provisions of part 7 of subtitle B of title 

20 I of the Employee Retirement Income Security Act of 

21 1974, the provisions of parts A and C of title XXVII of 

22 the Public Health Service Act, and chapter 100 of the In23 ternal Revenue Code of 1986’’. 

Æ 


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