HR 1916 RFS
tive than the predominant coverage limits and 
cost-sharing requirements, 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 health insurance coverage offered by a 
health insurance issuer, inpatient and out-
patient items and services performed to im-
prove, repair, or restore bodily function (or per-
formed to approximate a normal appearance), 
due to a congenital anomaly or birth defect, and 
includes treatment to any and all missing or ab-
normal 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, in-
cluding— 
‘‘(i) any items or services, including 
inpatient and outpatient care, reconstruc-
tive services and procedures, and complica-
tions thereof; 
VerDate Sep 11 2014 
23:32 Apr 05, 2022
Jkt 029200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H1916.RFS
H1916
kjohnson on DSK79L0C42PROD with BILLS
HR 1916 RFS
‘‘(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 
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 health insurance coverage, shall, in accordance with 
regulations or guidance issued by the Secretary, provide 
to each participant or beneficiary under such plan or cov-
erage a written description of the terms of this section. 
VerDate Sep 11 2014 
23:32 Apr 05, 2022
Jkt 029200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H1916.RFS
H1916
kjohnson on DSK79L0C42PROD with BILLS
HR 1916 RFS
Such description shall be in language which is understand-
able to the typical participant or beneficiary.’’. 
(2) TECHNICAL
AMENDMENT.—The table of 
contents in section 1 of such Act is amended by in-
serting after the item relating to section 725 the fol-
lowing new item: 
‘‘Sec. 726. Standards relating to benefits for congential 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 is amend-
ed by adding at the end the following: 
‘‘SEC. 9826. 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 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, 
VerDate Sep 11 2014 
23:32 Apr 05, 2022
Jkt 029200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H1916.RFS
H1916
kjohnson on DSK79L0C42PROD with BILLS
HR 1916 RFS
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 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, that are 
no more restrictive than the predominant cov-
erage limits and cost-sharing requirements, re-
spectively, applied to substantially all medical 
and surgical benefits covered by the plan. 
‘‘(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, in-
patient and outpatient items and services per-
formed to improve, repair, or restore bodily 
function (or performed to approximate a normal 
appearance), due to a congenital anomaly or 
birth defect, and includes treatment to any and 
all missing or abnormal body parts (including 
VerDate Sep 11 2014 
23:32 Apr 05, 2022
Jkt 029200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H1916.RFS
H1916
kjohnson on DSK79L0C42PROD with BILLS
HR 1916 RFS
teeth, the oral cavity, and their associated 
structures) that would otherwise be provided 
under the plan 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 
with the underlying congenital anomaly or 
birth defect. 
‘‘(B) EXCEPTION.—The term ‘treatment’ 
shall not include cosmetic surgery performed to 
VerDate Sep 11 2014 
23:32 Apr 05, 2022
Jkt 029200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H1916.RFS
H1916
kjohnson on DSK79L0C42PROD with BILLS