Ensuring Lasting Smiles Act

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. Short title This Act may be cited as the Ensuring Lasting Smiles Act 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 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 (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 (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) section 2704 sections 2725 and 2730 (B) Section 2762(b)(2) of the Public Health Service Act ( 42 U.S.C. 300gg–62(b)(2) section 2751 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: 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 (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 (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) section 711 sections 711 and 716 (B) Section 732(a) of such Act ( 29 U.S.C. 1191a(a) section 711 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 Public Law 111–148 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 (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 . (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) (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) 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

Summary: 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.