I 
115TH CONGRESS 
2D SESSION 
H. R. 6689 
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 
AUGUST 28, 2018 
Mr. PETERSON (for himself, Mr. YOUNG of Iowa, Mr. YODER, Mr. MCGOV-
ERN, and Mr. FASO) introduced the following bill; which was referred to 
the Committee on Energy and Commerce, and in addition to the Commit-
tees on Ways and Means, and Education and the Workforce, for a period 
to be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee 
concerned 
A BILL 
To amend the Public Health Service Act, the Employee Re-
tirement Income Security Act of 1974, and the Internal 
Revenue Code of 1986 to require that group and indi-
vidual health insurance coverage and group health plans 
provide coverage for treatment of a congenital anomaly 
or birth defect. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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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.— 
(1) IN GENERAL.—Title XXVII of the Public 
Health Service Act is amended by inserting after 
section 2728 (42 U.S.C. 300gg–28), the following: 
‘‘SEC. 2729. STANDARDS RELATING TO BENEFITS FOR CON-
GENITAL ANOMALY OR BIRTH DEFECT. 
‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC-
TIVE 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 diag-
nosis 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 
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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 limita-
tions applied to substantially all medical and sur-
gical 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’ includes patient and outpatient care 
and services performed to improve or restore 
body function (or performed to approximate a 
normal appearance), due to congenital anomaly 
or birth defect and shall include treatment to 
any and all missing or abnormal body parts, 
(including teeth, the oral cavity, and their asso-
ciated structures) that would otherwise be pro-
vided under the plan or coverage for any other 
injury and sickness, including— 
‘‘(i) inpatient and outpatient care, re-
constructive services and procedures, and 
complications thereof, including prosthetics 
and appliances; 
‘‘(ii) adjunctive dental, orthodontic or 
prosthodontic support from birth until the 
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medical or surgical treatment of the defect 
or anomaly has been completed, including 
ongoing or subsequent treatment required 
to maintain function or approximate a nor-
mal appearance; 
‘‘(iii) procedures that do not materi-
ally restore or improve the function of the 
body part being treated; and 
‘‘(iv) procedures for secondary condi-
tions and follow-up treatment. 
‘‘(B) EXCEPTION.—The term ‘treatment’ 
shall not include cosmetic surgery performed to 
reshape normal structures of the body to im-
prove appearance or self-esteem. 
‘‘(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)) is amend-
ed by striking ‘‘section 2704’’ and inserting 
‘‘sections 2725 and 2729’’. 
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(B) Section 2762(b)(2) of the Public 
Health Service Act (42 U.S.C. 300gg–62(b)(2)) 
is amended by striking ‘‘section 2751’’ and in-
serting ‘‘sections 2729 and 2751’’. 
(b) ERISA AMENDMENTS.— 
(1) IN GENERAL.—Subpart B of part 7 of sub-
title B of title I of the Employee Retirement Income 
Security Act of 1974 is amended by adding at the 
end the following: 
‘‘SEC. 716. STANDARDS RELATING TO BENEFITS FOR CON-
GENITAL ANOMALY OR BIRTH DEFECT. 
‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE TREAT-
MENT.— 
‘‘(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 diag-
nosis 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 
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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 limita-
tions applied to substantially all medical and sur-
gical 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’ includes patient and outpatient care 
and services performed to improve or restore 
body function (or performed to approximate a 
normal appearance), due to congenital anomaly 
or birth defect and shall include treatment to 
any and all missing or abnormal body parts, 
(including teeth, the oral cavity, and their asso-
ciated structures) that would otherwise be pro-
vided under the plan or coverage for any other 
injury and sickness, including— 
‘‘(i) inpatient and outpatient care, re-
constructive services and procedures, and 
complications thereof, including prosthetics 
and appliances; 
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‘‘(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 nor-
mal appearance; 
‘‘(iii) procedures that do not materi-
ally restore or improve the function of the 
body part being treated; and 
‘‘(iv) procedures for secondary condi-
tions and follow-up treatment. 
‘‘(B) EXCEPTION.—The term ‘treatment’ 
shall not include cosmetic surgery performed to 
reshape normal structures of the body to im-
prove appearance or self-esteem. 
‘‘(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 pur-
poses 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 
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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)) is amended by striking ‘‘section 711’’ 
and inserting ‘‘sections 711 and 716’’. 
(B) Section 732(a) of such Act (29 U.S.C. 
1191a(a)) is amended by striking ‘‘section 711’’ 
and inserting ‘‘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 de-
fect.’’. 
(c) INTERNAL REVENUE CODE AMENDMENTS.— 
(1) IN
GENERAL.—Subchapter B of chapter 
100 of the Internal Revenue Code of 1986, as 
amended by subsection (f) of the section 1563 (relat-
ing to conforming amendments) of Public Law 111– 
148, is amended by adding at the end the following: 
‘‘SEC. 9816. STANDARDS RELATING TO BENEFITS FOR CON-
GENITAL ANOMALY OR BIRTH DEFECT. 
‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE TREAT-
MENT.—A group health plan, and a health insurance 
issuer offering group or individual health insurance cov-
erage, shall provide coverage for outpatient and inpatient 
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services related to the diagnosis and treatment of a con-
genital anomaly or birth defect. 
‘‘(b) REQUIREMENTS.—Coverage provided under 
subsection (a) shall include any service to functionally im-
prove, repair, or restore any body part that is medically 
necessary to achieve normal body functioning or appear-
ance, 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 re-
quired 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 para-
graph (2), in this section, the term ‘treatment’ in-
cludes patient and outpatient care and services per-
formed to improve or restore body function (or per-
formed to approximate a normal appearance), due to 
congenital anomaly or birth defect and shall include 
treatment to any and all missing or abnormal body 
parts, (including teeth, the oral cavity, and their as-
sociated structures) that would otherwise be pro-
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vided under the plan or coverage for any other in-
jury and sickness, including— 
‘‘(A) inpatient and outpatient care, recon-
structive services and procedures, and complica-
tions thereof, including prosthetics and appli-
ances; 
‘‘(B) adjunctive dental, orthodontic or 
prosthodontic support from birth until the med-
ical 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 re-
store 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’ shall 
not include cosmetic surgery performed to reshape 
normal structures of the body to improve appearance 
or self-esteem.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions 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 de-
fect.’’. 
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