Ensuring Lasting Smiles Act

IIB 117TH CONGRESS 2D SESSION H. R. 1916 IN THE SENATE OF THE UNITED STATES APRIL 5, 2022 Received; read twice and referred to the Committee on Health, Education, Labor, and Pensions AN ACT To provide health insurance benefits for outpatient and inpa- tient 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 Representa- 1 tives of the United States of America in Congress assembled, 2 VerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916 kjohnson on DSK79L0C42PROD with BILLS 2 HR 1916 RFS SECTION 1. SHORT TITLE. 1 This Act may be cited as the ‘‘Ensuring Lasting 2 Smiles Act’’. 3 SEC. 2. COVERAGE OF CONGENITAL ANOMALY OR BIRTH 4 DEFECT. 5 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.— 6 Part D of title XXVII of the Public Health Service Act 7 (42 U.S.C. 300gg–111 et seq.) is amended by adding at 8 the end the following new section: 9 ‘‘SEC. 2799A–11. STANDARDS RELATING TO BENEFITS FOR 10 CONGENITAL ANOMALY OR BIRTH DEFECT. 11 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC- 12 TIVE TREATMENT.— 13 ‘‘(1) IN GENERAL.—A group health plan, and a 14 health insurance issuer offering group or individual 15 health insurance coverage, shall provide coverage for 16 outpatient and inpatient items and services related 17 to the diagnosis and treatment of a congenital 18 anomaly or birth defect. 19 ‘‘(2) REQUIREMENTS.— 20 ‘‘(A) IN GENERAL.—Coverage provided 21 under paragraph (1) shall include any medically 22 necessary item or service to functionally im- 23 prove, repair, or restore any body part to 24 achieve normal body functioning or appearance, 25 as determined by the treating physician (as de- 26 VerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916 kjohnson on DSK79L0C42PROD with BILLS 3 HR 1916 RFS fined in section 1861(r) of the Social Security 1 Act), due to congenital anomaly or birth defect. 2 ‘‘(B) FINANCIAL REQUIREMENTS AND 3 TREATMENT REQUIREMENTS.—Any coverage 4 provided under paragraph (1) under a group 5 health plan or individual or group health insur- 6 ance coverage offered by a health insurance 7 issuer may be subject to coverage limits (such 8 as medical necessity, pre-authorization, or pre- 9 certification) and cost-sharing requirements 10 (such as coinsurance, copayments, and 11 deductibles), as required by the plan or issuer, 12 that are no more restrictive than the predomi- 13 nant coverage limits and cost-sharing require- 14 ments, respectively, applied to substantially all 15 medical and surgical benefits covered by the 16 plan (or coverage). 17 ‘‘(3) TREATMENT DEFINED.—In this section: 18 ‘‘(A) IN GENERAL.—Except as provided in 19 subparagraph (B), the term ‘treatment’ in- 20 cludes, with respect to a group health plan or 21 group or individual health insurance coverage 22 offered by a health insurance issuer, inpatient 23 and outpatient items and services performed to 24 improve, repair, or restore bodily function (or 25 VerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916 kjohnson on DSK79L0C42PROD with BILLS 4 HR 1916 RFS performed to approximate a normal appear- 1 ance), due to a congenital anomaly or birth de- 2 fect, and includes treatment to any and all 3 missing or abnormal body parts (including 4 teeth, the oral cavity, and their associated 5 structures) that would otherwise be provided 6 under the plan or coverage for any other injury 7 or sickness, including— 8 ‘‘(i) any items or services, including 9 inpatient and outpatient care, reconstruc- 10 tive services and procedures, and complica- 11 tions thereof; 12 ‘‘(ii) adjunctive dental, orthodontic, or 13 prosthodontic support from birth until the 14 medical or surgical treatment of the defect 15 or anomaly has been completed, including 16 ongoing or subsequent treatment required 17 to maintain function or approximate a nor- 18 mal appearance; 19 ‘‘(iii) procedures that materially im- 20 prove, repair, or restore bodily function; 21 and 22 ‘‘(iv) procedures for secondary condi- 23 tions and follow-up treatment associated 24 VerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916 kjohnson on DSK79L0C42PROD with BILLS 5 HR 1916 RFS with the underlying congenital anomaly or 1 birth defect. 2 ‘‘(B) EXCEPTION.—The term ‘treatment’ 3 shall not include cosmetic surgery performed to 4 reshape normal structures of the body to im- 5 prove appearance or self-esteem. 6 ‘‘(b) NOTICE.—Not later than one year after the date 7 of the enactment of this section and annually thereafter, 8 a group health plan, and a health insurance issuer offering 9 group or individual health insurance coverage, shall, in ac- 10 cordance with regulations or guidance issued by the Sec- 11 retary, provide to each enrollee under such plan or cov- 12 erage a written description of the terms of this section. 13 Such description shall be in language which is understand- 14 able to the typical enrollee.’’. 15 (b) ERISA AMENDMENTS.— 16 (1) IN GENERAL.—Subpart B of part 7 of sub- 17 title B of title I of the Employee Retirement Income 18 Security Act of 1974 is amended by adding at the 19 end the following: 20 ‘‘SEC. 726. STANDARDS RELATING TO BENEFITS FOR CON- 21 GENITAL ANOMALY OR BIRTH DEFECT. 22 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC- 23 TIVE TREATMENT.— 24 VerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916 kjohnson on DSK79L0C42PROD with BILLS 6 HR 1916 RFS ‘‘(1) IN GENERAL.—A group health plan, and a 1 health insurance issuer offering group health insur- 2 ance coverage, shall provide coverage for outpatient 3 and inpatient items and services related to the diag- 4 nosis and treatment of a congenital anomaly or birth 5 defect. 6 ‘‘(2) REQUIREMENTS.— 7 ‘‘(A) IN GENERAL.—Coverage provided 8 under paragraph (1) shall include any medically 9 necessary item or service to functionally im- 10 prove, repair, or restore any body part to 11 achieve normal body functioning or appearance, 12 as determined by the treating physician (as de- 13 fined in section 1861(r) of the Social Security 14 Act), due to congenital anomaly or birth defect. 15 ‘‘(B) FINANCIAL REQUIREMENTS AND 16 TREATMENT REQUIREMENTS.—Any coverage 17 provided under paragraph (1) under a group 18 health plan or group health insurance coverage 19 offered by a health insurance issuer may be 20 subject to coverage limits (such as medical ne- 21 cessity, pre-authorization, or pre-certification) 22 and cost-sharing requirements (such as coinsur- 23 ance, copayments, and deductibles), as required 24 by the plan or issuer, that are no more restric- 25 VerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H1916.RFS H1916 kjohnson on DSK79L0C42PROD with BILLS 7 HR 1916 RFS tive than the predominant coverage limits and 1 cost-sharing requirements, respectively, applied 2 to substantially all medical and surgical benefits 3 covered by the plan (or coverage). 4 ‘‘(3) TREATMENT DEFINED.—In this section: 5 ‘‘(A) IN GENERAL.—Except as provided in 6 subparagraph (B), the term ‘treatment’ in- 7 cludes, with respect to a group health plan or 8 group health insurance coverage offered by a 9 health insurance issuer, inpatient and out- 10 patient items and services performed to im- 11 prove, repair, or restore bodily function (or per- 12 formed to approximate a normal appearance), 13 due to a congenital anomaly or birth defect, and 14 includes treatment to any and all missing or ab- 15 normal body parts (including teeth, the oral 16 cavity, and their associated structures) that 17 would otherwise be provided under the plan or 18 coverage for any other injury or sickness, in- 19 cluding— 20 ‘‘(i) any items or services, including 21 inpatient and outpatient care, reconstruc- 22 tive services and procedures, and complica- 23 tions thereof; 24 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 8 HR 1916 RFS ‘‘(ii) adjunctive dental, orthodontic, or 1 prosthodontic support from birth until the 2 medical or surgical treatment of the defect 3 or anomaly has been completed, including 4 ongoing or subsequent treatment required 5 to maintain function or approximate a nor- 6 mal appearance; 7 ‘‘(iii) procedures that materially im- 8 prove, repair, or restore bodily function; 9 and 10 ‘‘(iv) procedures for secondary condi- 11 tions and follow-up treatment associated 12 with the underlying congenital anomaly or 13 birth defect. 14 ‘‘(B) EXCEPTION.—The term ‘treatment’ 15 shall not include cosmetic surgery performed to 16 reshape normal structures of the body to im- 17 prove appearance or self-esteem. 18 ‘‘(b) NOTICE.—Not later than one year after the date 19 of the enactment of this section and annually thereafter, 20 a group health plan, and a health insurance issuer offering 21 group health insurance coverage, shall, in accordance with 22 regulations or guidance issued by the Secretary, provide 23 to each participant or beneficiary under such plan or cov- 24 erage a written description of the terms of this section. 25 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 9 HR 1916 RFS Such description shall be in language which is understand- 1 able to the typical participant or beneficiary.’’. 2 (2) TECHNICAL AMENDMENT.—The table of 3 contents in section 1 of such Act is amended by in- 4 serting after the item relating to section 725 the fol- 5 lowing new item: 6 ‘‘Sec. 726. Standards relating to benefits for congential anomaly or birth de- fect.’’. (c) INTERNAL REVENUE CODE AMENDMENTS.— 7 (1) IN GENERAL.—Subchapter B of chapter 8 100 of the Internal Revenue Code of 1986 is amend- 9 ed by adding at the end the following: 10 ‘‘SEC. 9826. STANDARDS RELATING TO BENEFITS FOR CON- 11 GENITAL ANOMALY OR BIRTH DEFECT. 12 ‘‘(a) REQUIREMENTS FOR CARE AND RECONSTRUC- 13 TIVE TREATMENT.— 14 ‘‘(1) IN GENERAL.—A group health plan shall 15 provide coverage for outpatient and inpatient items 16 and services related to the diagnosis and treatment 17 of a congenital anomaly or birth defect. 18 ‘‘(2) REQUIREMENTS.— 19 ‘‘(A) IN GENERAL.—Coverage provided 20 under paragraph (1) shall include any medically 21 necessary item or service to functionally im- 22 prove, repair, or restore any body part to 23 achieve normal body functioning or appearance, 24 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 10 HR 1916 RFS as determined by the treating physician (as de- 1 fined in section 1861(r) of the Social Security 2 Act), due to congenital anomaly or birth defect. 3 ‘‘(B) FINANCIAL REQUIREMENTS AND 4 TREATMENT REQUIREMENTS.—Any coverage 5 provided under paragraph (1) under a group 6 health plan may be subject to coverage limits 7 (such as medical necessity, pre-authorization, or 8 pre-certification) and cost-sharing requirements 9 (such as coinsurance, copayments, and 10 deductibles), as required by the plan, that are 11 no more restrictive than the predominant cov- 12 erage limits and cost-sharing requirements, re- 13 spectively, applied to substantially all medical 14 and surgical benefits covered by the plan. 15 ‘‘(3) TREATMENT DEFINED.—In this section: 16 ‘‘(A) IN GENERAL.—Except as provided in 17 subparagraph (B), the term ‘treatment’ in- 18 cludes, with respect to a group health plan, in- 19 patient and outpatient items and services per- 20 formed to improve, repair, or restore bodily 21 function (or performed to approximate a normal 22 appearance), due to a congenital anomaly or 23 birth defect, and includes treatment to any and 24 all missing or abnormal body parts (including 25 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 11 HR 1916 RFS teeth, the oral cavity, and their associated 1 structures) that would otherwise be provided 2 under the plan for any other injury or sickness, 3 including— 4 ‘‘(i) any items or services, including 5 inpatient and outpatient care, reconstruc- 6 tive services and procedures, and complica- 7 tions thereof; 8 ‘‘(ii) adjunctive dental, orthodontic, or 9 prosthodontic support from birth until the 10 medical or surgical treatment of the defect 11 or anomaly has been completed, including 12 ongoing or subsequent treatment required 13 to maintain function or approximate a nor- 14 mal appearance; 15 ‘‘(iii) procedures that materially im- 16 prove, repair, or restore bodily function; 17 and 18 ‘‘(iv) procedures for secondary condi- 19 tions and follow-up treatment associated 20 with the underlying congenital anomaly or 21 birth defect. 22 ‘‘(B) EXCEPTION.—The term ‘treatment’ 23 shall not include cosmetic surgery performed to 24 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 12 HR 1916 RFS reshape normal structures of the body to im- 1 prove appearance or self-esteem. 2 ‘‘(b) NOTICE.—Not later than one year after the date 3 of the enactment of this section and annually thereafter, 4 a group health plan shall, in accordance with regulations 5 or guidance issued by the Secretary, provide to each en- 6 rollee under such plan a written description of the terms 7 of this section. Such description shall be in language which 8 is understandable to the typical enrollee.’’. 9 (2) CLERICAL AMENDMENT.—The table of sec- 10 tions for such subchapter is amended by adding at 11 the end the following new item: 12 ‘‘Sec. 9826. Standards relating to benefits for congenital anomaly or birth de- fect.’’. (d) RULE OF CONSTRUCTION.—A group health plan 13 or health insurance issuer shall provide the benefits de- 14 scribed in section 2799A–11 of the Public Health Service 15 Act (as added by subsection (a)), section 726 of the Em- 16 ployee Retirement Income Security Act of 1974 (as added 17 by subsection (b)), and section 9826 of the Internal Rev- 18 enue Code of 1986 (as added by subsection (c)) under the 19 terms of such plan or health insurance coverage offered 20 by such issuer. 21 (e) EFFECTIVE DATE.—The amendments made by 22 this section shall apply with respect to plan years begin- 23 ning on or after January 1, 2024. 24 VerDate Sep 11 2014 23:32 Apr 05, 2022 Jkt 029200 PO 00000 Frm 00012 Fmt 6652 Sfmt [Text truncated for display. Full text available on Congress.gov.]