lying congenital anomaly or birth de-
fect. 
‘‘(B) EXCEPTION.—The items and services 
required under this subsection to be covered by 
a group health plan or health insurance issuer 
offering group or individual health insurance 
coverage shall not include cosmetic surgery per-
formed to reshape normal structures of the 
body to improve appearance or self-esteem, if 
such items and services are not furnished as a 
result of a medical determination of a con-
genital anomaly or birth defect. 
‘‘(b) NOTICE.—Beginning not later January 1, 2026, 
a group health plan or health insurance issuer offering 
group or individual health insurance coverage shall provide 
notice to each participant and beneficiary under such plan 
or coverage regarding the coverage required by this section 
in any documents describing services, in accordance with 
any regulations promulgated by the Secretary. 
‘‘(c) DEFINITION.—In this section, the term ‘con-
genital anomaly or birth defect’ means a structural or 
functional anomaly that occurs during intrauterine life, 
develops prenatally, and may be identified before birth, at 
birth, or later in life, and which may— 
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‘‘(1) be caused by genetic or chromosomal dis-
orders, embryotoxic or teratogenic environmental 
factors, nutrient deficiency, multifactorial inherit-
ance, or be of an unknown cause; 
‘‘(2) manifest as abnormal anatomical struc-
tures; 
‘‘(3) manifest as physical, sensory, or cognitive 
functional disabilities; 
‘‘(4) manifest as syndromes, diseases, or other 
health problems; and 
‘‘(5) manifest as singular anomalies or in com-
bination prenatally, at birth, or later in life.’’. 
(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. COVERAGE OF 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 health insur-
ance coverage, shall provide coverage for outpatient 
and inpatient items and services related to the diag-
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nosis and treatment of a congenital anomaly or birth 
defect that primarily impacts the appearance or 
function of the eyes, ears, teeth, mouth, or jaw, con-
sistent with paragraphs (2) and (3). 
‘‘(2) FINANCIAL
REQUIREMENTS.—Any cov-
erage provided under paragraph (1) under a group 
health plan or group health insurance coverage of-
fered by a health insurance issuer may be subject to 
cost-sharing requirements (such as coinsurance, co-
payments, and deductibles), as required by the plan 
or issuer offering such coverage, that are no more 
restrictive than the predominant cost-sharing re-
quirements applied to substantially all other medical 
and surgical benefits covered by the plan or cov-
erage. 
‘‘(3) APPLICABLE ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—Except as provided in 
subparagraph (B), the items and services re-
quired under paragraph (1) to be covered by a 
group health plan or group health insurance 
coverage offered by a health insurance issuer 
include— 
‘‘(i) any item or service to improve, 
repair, or restore any body part to achieve 
normal body functioning or appearance, or 
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performed to approximate a normal ap-
pearance, as determined medically nec-
essary by the treating physician (as de-
fined in section 1861(r) of the Social Secu-
rity Act), on account of a congenital anom-
aly or birth defect that primarily impacts 
the appearance or function of the eyes, 
ears, teeth, mouth, or jaw; and 
‘‘(ii) any treatment or diagnostic serv-
ice with respect to any and all missing or 
abnormal body parts (including teeth, the 
oral cavity, and their associated struc-
tures), as determined medically necessary 
by the treating physician (as defined in 
section 1861(r) of the Social Security Act), 
including— 
‘‘(I) reconstructive services and 
procedures, and items and services re-
lated to any complications arising 
from such services and procedures; 
‘‘(II) adjunctive dental, ortho-
dontic, or prosthodontic support from 
birth until the medical or surgical 
treatment of the defect or anomaly 
has been completed, including ongoing 
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or subsequent treatment required to 
maintain function or approximate a 
normal appearance, notwithstanding 
any exclusions, limitations, or restric-
tions under the plan or health insur-
ance coverage on coverage of dental, 
orthodontic, or prosthodontic items 
and services arising from other inju-
ries or sicknesses; and 
‘‘(III) items and services related 
to secondary conditions and follow-up 
treatment associated with the under-
lying congenital anomaly or birth de-
fect. 
‘‘(B) EXCEPTION.—The items and services 
required under this subsection to be covered by 
a group health plan or health insurance issuer 
offering group health insurance coverage shall 
not include cosmetic surgery performed to re-
shape normal structures of the body to improve 
appearance or self-esteem, if such items and 
services are not furnished as a result of a med-
ical determination of a congenital anomaly or 
birth defect. 
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