Title: Ensuring Lasting Smiles Act
Policy area: Health

Summary:
Ensuring Lasting Smiles Act
This bill requires private health insurance plans to cover diagnosis and treatment services for congenital anomalies and birth defects, such as reconstructive services and prosthetics. Coverage must include services 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.

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 560 Introduced in Senate (IS)]

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116th CONGRESS
  1st Session
                                 S. 560

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 SENATE OF THE UNITED STATES

                           February 26, 2019

  Ms. Baldwin (for herself, Ms. Ernst, Ms. Murkowski, and Mr. Brown) 
introduced the following bill; which was read twice and referred to the 
          Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
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.

    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.--
            (1) In general.--Title XXVII of the Public Health Service 
        Act is amended by inserting after section 2729 (42 U.S.C. 
        300gg-19b), the following:

``SEC. 2730. 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 
        services related to the diagnosis 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 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 limitations 
        applied to substantially all medical and surgical 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 
                associated structures) that would otherwise be provided 
                under the plan or coverage for any other injury and 
                sickness, including--
                            ``(i) inpatient and outpatient care, 
                        reconstructive services and procedures, and 
                        complications thereof, including prosthetics 
                        and appliances;
                            ``(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 do not materially 
                        restore or improve the function of the body 
                        part being treated; and
                            ``(iv) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(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(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 amended by striking 
                ``section 2704'' and inserting ``sections 2725 and 
                2730''.
                    (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 inserting ``sections 2730 and 
                2751''.
    (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. 716. STANDARDS RELATING TO BENEFITS FOR CONGENITAL ANOMALY OR 
              BIRTH DEFECT.

    ``(a) Requirements for 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 
        services related to the diagnosis 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 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 limitations 
        applied to substantially all medical and surgical 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 
                associated structures) that would otherwise be provided 
                under the plan or coverage for any other injury and 
                sickness, including--
                            ``(i) inpatient and outpatient care, 
                        reconstructive services and procedures, and 
                        complications thereof, including prosthetics 
                        and appliances;
                            ``(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 do not materially 
                        restore or improve the function of the body 
                        part being treated; and
                            ``(iv) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(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 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 purposes 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 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 defect.
    (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 (relating to conforming amendments) of Public 
        Law 111-148, is amended by adding at the end the following:

``SEC. 9816. STANDARDS RELATING TO BENEFITS FOR CONGENITAL ANOMALY OR 
              BIRTH DEFECT.

    ``(a) Requirements for Reconstructive Treatment.--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 diagnosis and treatment of a congenital anomaly 
or birth defect.
    ``(b) Requirements.--Coverage provided under subsection (a) 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 under such subsection 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 
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 paragraph (2), 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 associated 
        structures) that would otherwise be provided under the plan or 
        coverage for any other injury and sickness, including--
                    ``(A) inpatient and outpatient care, reconstructive 
                services and procedures, and complications thereof, 
                including prosthetics and appliances;
                    ``(B) 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;
                    ``(C) procedures that do not materially restore 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 sections 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 defect.''.
    (d) 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 2730 (relating to standards 
                        relating to benefits for congenital anomaly or 
                        birth defect), as added by section 2(a) of the 
                        Ensuring Lasting Smiles Act.''.
    (e) 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, 2020, and with respect to health insurance coverage 
offered, sold, issued, renewed, in effect, or operated in the 
individual market on or after such date.
    (f) 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 and C of title XXVII of the Public Health Service 
Act, and chapter 100 of the Internal Revenue Code of 1986''.
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