Ensuring Lasting Smiles Act
Bill: S.754 | Sponsor: Sen. Baldwin, Tammy (D-WI)
Policy area: Health

Summary:
Ensuring Lasting Smiles Act
This bill requires private health insurance plans to cover diagnosis and treatment of congenital anomalies and birth defects, such as reconstructive services and items. Coverage must include services and items 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. Coverage limits and cost-sharing requirements for such services and items may not be more restrictive than those applicable to all medical and surgical benefits under the plan.

To provide health insurance benefits for outpatient and inpatient items 
  and services related to the diagnosis and treatment of a congenital 
                        anomaly or birth defect.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

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 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 
        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 improve, repair, or 
                restore any body part to achieve normal body 
                functioning or appearance, as determined by the 
                treating physician (as defined 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 insurance 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 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' includes, 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 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 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, reconstructive 
                        services and procedures, and complications 
                        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 normal appearance;
                            ``(iii) procedures that materially improve, 
                        repair, or restore bodily function; and
                            ``(iv) procedures for secondary conditions 
                        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 improve appearance or self-
                esteem.
    ``(b) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 714(c) 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.''.
    (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:

``SEC. 726. 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 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 improve, repair, or 
                restore any body part to achieve normal body 
                functioning or appearance, as determined by the 
                treating physician (as defined 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 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 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' includes, with 
                respect to a group health plan or group health 
                insurance coverage offered by a health insurance 
                issuer, inpatient and outpatient items and services 
                performed 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 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, reconstructive 
                        services and procedures, and complications 
                        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 normal appearance;
                            ``(iii) procedures that materially improve, 
                        repair, or restore bodily function; and
                            ``(iv) procedures for secondary conditions 
                        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 improve appearance or self-
                esteem.
    ``(b) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 714(c) with respect to the 
requirements of this section as if such section applied to such 
plan.''.
            (2) Technical amendments.--
                    (A) Section 732(a) of such Act (29 U.S.C. 1191a(a)) 
                is amended by striking ``section 711'' and inserting 
                ``sections 711 and 726''.
                    (B) The table of contents in section 1 of such Act 
                is amended by inserting after the item relating to 
                section 725 the following new item:

``Sec. 726. Standards relating to benefits for congenital anomaly or 
                            birth defect.''
    (c) Internal Revenue Code Amendments.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986 is amended by adding at the end 
        the following:

``SEC. 9826. STANDARDS RELATING TO BENEFITS FOR CONGENITAL ANOMALY OR 
              BIRTH DEFECT.

    ``(a) Requirements for Care and Reconstructive 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 improve, repair, or 
                restore any body part to achieve normal body 
                functioning or appearance, as determined by the 
                treating physician (as defined 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 coverage limits and 
                cost-sharing requirements, respectively, 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' includes, with 
                respect to a group health plan, inpatient and 
                outpatient items and services performed 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 
                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, reconstructive 
                        services and procedures, and complications 
                        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 normal appearance;
                            ``(iii) procedures that materially improve, 
                        repair, or restore bodily function; and
                            ``(iv) procedures for secondary conditions 
                        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 improve appearance or self-
                esteem.
    ``(b) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 714(c) 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) Clerical amendment.--The table of sections for such 
        subchapter is amended by adding at the end the following new 
        item:

``Sec. 9826. Standards relating to benefits for congenital anomaly or 
                            birth defect.''.
    (d) Rule of Construction.--A group health plan or health insurance 
issuer shall provide the benefits described in section 2799A-11 of the 
Public Health Service Act (as added by subsection (a)), section 726 of 
the Employee Retirement Income Security Act of 1974 (as added by 
subsection (b)), and section 9826 of the Internal Revenue Code of 1986 
(as added by subsection (c)) under the terms of such plan or health 
insurance coverage offered by such issuer.
    (e) 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)), is amended by adding at the end 
the following:
                            ``(v) Section 2799A-11 (relating to 
                        standards relating to benefits for congenital 
                        anomaly or birth defect), as added by section 
                        2(a) of the Ensuring Lasting Smiles Act.''.
    (f) 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, 2022, and with respect to health insurance coverage 
offered, sold, issued, renewed, in effect, or operated in the 
individual market on or after such date.
    (g) 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)'' and inserting ``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, C, and D of title XXVII of the Public Health 
Service Act, and chapter 100 of the Internal Revenue Code of 1986''.
                                 <all>