HR 1916 RFS
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.— 
Part D of title XXVII of the Public Health Service Act 
(42 U.S.C. 300gg–111 et seq.) is amended by adding at 
the end the following new section: 
‘‘SEC. 2799A–11. STANDARDS RELATING TO BENEFITS FOR 
CONGENITAL 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 items and services related 
to the diagnosis and treatment of a congenital 
anomaly or birth defect. 
‘‘(2) REQUIREMENTS.— 
‘‘(A) IN
GENERAL.—Coverage provided 
under paragraph (1) shall include any medically 
necessary item or service to functionally im-
prove, repair, or restore any body part to 
achieve normal body functioning or appearance, 
as determined by the treating physician (as de-
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fined in section 1861(r) of the Social Security 
Act), due to congenital anomaly or birth defect. 
‘‘(B) 
FINANCIAL
REQUIREMENTS
AND 
TREATMENT
REQUIREMENTS.—Any coverage 
provided under paragraph (1) under a group 
health plan or individual or group health insur-
ance coverage offered by a health insurance 
issuer may be subject to coverage limits (such 
as medical necessity, pre-authorization, or pre- 
certification) and cost-sharing requirements 
(such 
as 
coinsurance, 
copayments, 
and 
deductibles), as required by the plan or issuer, 
that are no more restrictive than the predomi-
nant coverage limits and cost-sharing require-
ments, respectively, applied to substantially all 
medical and surgical benefits covered by the 
plan (or coverage). 
‘‘(3) TREATMENT DEFINED.—In this section: 
‘‘(A) IN GENERAL.—Except as provided in 
subparagraph (B), the term ‘treatment’ in-
cludes, with respect to a group health plan or 
group or individual health insurance coverage 
offered by a health insurance issuer, inpatient 
and outpatient items and services performed to 
improve, repair, or restore bodily function (or 
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performed to approximate a normal appear-
ance), due to a congenital anomaly or birth de-
fect, and includes treatment to any and all 
missing or abnormal body parts (including 
teeth, the oral cavity, and their associated 
structures) that would otherwise be provided 
under the plan or coverage for any other injury 
or sickness, including— 
‘‘(i) any items or services, including 
inpatient and outpatient care, reconstruc-
tive services and procedures, and complica-
tions thereof; 
‘‘(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 materially im-
prove, repair, or restore bodily function; 
and 
‘‘(iv) procedures for secondary condi-
tions and follow-up treatment associated 
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with the underlying congenital anomaly or 
birth defect. 
‘‘(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.—Not later than one year after the date 
of the enactment of this section and annually thereafter, 
a group health plan, and a health insurance issuer offering 
group or individual health insurance coverage, shall, in ac-
cordance with regulations or guidance issued by the Sec-
retary, provide to each enrollee under such plan or cov-
erage a written description of the terms of this section. 
Such description shall be in language which is understand-
able to the typical enrollee.’’. 
(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. 726. STANDARDS RELATING TO BENEFITS FOR CON-
GENITAL ANOMALY OR BIRTH DEFECT. 
‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC-
TIVE TREATMENT.— 
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‘‘(1) IN GENERAL.—A group health plan, and a 
health insurance issuer offering group health insur-
ance coverage, shall provide coverage for outpatient 
and inpatient items and services related to the diag-
nosis and treatment of a congenital anomaly or birth 
defect. 
‘‘(2) REQUIREMENTS.— 
‘‘(A) IN
GENERAL.—Coverage provided 
under paragraph (1) shall include any medically 
necessary item or service to functionally im-
prove, repair, or restore any body part to 
achieve normal body functioning or appearance, 
as determined by the treating physician (as de-
fined in section 1861(r) of the Social Security 
Act), due to congenital anomaly or birth defect. 
‘‘(B) 
FINANCIAL
REQUIREMENTS
AND 
TREATMENT
REQUIREMENTS.—Any coverage 
provided under paragraph (1) under a group 
health plan or group health insurance coverage 
offered by a health insurance issuer may be 
subject to coverage limits (such as medical ne-
cessity, pre-authorization, or pre-certification) 
and cost-sharing requirements (such as coinsur-
ance, copayments, and deductibles), as required 
by the plan or issuer, that are no more restric-
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