Ensuring Lasting Smiles Act

I 116TH CONGRESS 1ST SESSION H. R. 1379 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 HOUSE OF REPRESENTATIVES FEBRUARY 26, 2019 Mr. PETERSON (for himself, Mr. RIGGLEMAN, Mrs. AXNE, Miss RICE of New York, Mr. SIMPSON, Mr. VISCLOSKY, Mr. RODNEY DAVIS of Illinois, and Mr. STIVERS) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Labor, for a period to be subse- quently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend the Public Health Service Act, the Employee Re- tirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to require that group and indi- vidual 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 Representa- 1 tives of the United States of America in Congress assembled, 2 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 2 •HR 1379 IH 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 (1) IN GENERAL.—Title XXVII of the Public 7 Health Service Act is amended by inserting after 8 section 2729 (42 U.S.C. 300gg–28), the following: 9 ‘‘SEC. 2730. STANDARDS RELATING TO BENEFITS FOR CON- 10 GENITAL 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 services related to the diag- 17 nosis and treatment of a congenital anomaly or birth 18 defect. 19 ‘‘(2) REQUIREMENTS.—Coverage provided 20 under paragraph (1) shall include any service to 21 functionally improve, repair, or restore any body 22 part that is medically necessary to achieve normal 23 body functioning or appearance, as determined by 24 the treating physician (as defined in section 1861 of 25 the Social Security Act). Any coverage provided 26 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 3 •HR 1379 IH under such paragraph may be subject to coverage 1 limits, such as pre-authorization or pre-certification, 2 as required by the plan or issuer that are no more 3 restrictive than the predominant treatment limita- 4 tions applied to substantially all medical and sur- 5 gical benefits covered by the plan (or coverage). 6 ‘‘(3) TREATMENT DEFINED.— 7 ‘‘(A) IN GENERAL.—Except as provided in 8 subparagraph (B), in this section, the term 9 ‘treatment’ includes patient and outpatient care 10 and services performed to improve or restore 11 body function (or performed to approximate a 12 normal appearance), due to congenital anomaly 13 or birth defect and shall include treatment to 14 any and all missing or abnormal body parts, 15 (including teeth, the oral cavity, and their asso- 16 ciated structures) that would otherwise be pro- 17 vided under the plan or coverage for any other 18 injury and sickness, including— 19 ‘‘(i) inpatient and outpatient care, re- 20 constructive services and procedures, and 21 complications thereof, including prosthetics 22 and appliances; 23 ‘‘(ii) adjunctive dental, orthodontic or 24 prosthodontic support from birth until the 25 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 4 •HR 1379 IH medical or surgical treatment of the defect 1 or anomaly has been completed, including 2 ongoing or subsequent treatment required 3 to maintain function or approximate a nor- 4 mal appearance; 5 ‘‘(iii) procedures that do not materi- 6 ally restore or improve the function of the 7 body part being treated; and 8 ‘‘(iv) procedures for secondary condi- 9 tions and follow-up treatment. 10 ‘‘(B) EXCEPTION.—The term ‘treatment’ 11 shall not include cosmetic surgery performed to 12 reshape normal structures of the body to im- 13 prove appearance or self-esteem. 14 ‘‘(b) NOTICE.—A group health plan under this part 15 shall comply with the notice requirement under section 16 714(b) of the Employee Retirement Income Security Act 17 of 1974 with respect to the requirements of this section 18 as if such section applied to such plan.’’. 19 (2) TECHNICAL AMENDMENTS.— 20 (A) Section 2724(c) of the Public Health 21 Service Act (42 U.S.C. 300gg–23(c)) is amend- 22 ed by striking ‘‘section 2704’’ and inserting 23 ‘‘sections 2725 and 2729’’. 24 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 5 •HR 1379 IH (B) Section 2762(b)(2) of the Public 1 Health Service Act (42 U.S.C. 300gg–62(b)(2)) 2 is amended by striking ‘‘section 2751’’ and in- 3 serting ‘‘sections 2729 and 2751’’. 4 (b) ERISA AMENDMENTS.— 5 (1) IN GENERAL.—Subpart B of part 7 of sub- 6 title B of title I of the Employee Retirement Income 7 Security Act of 1974 is amended by adding at the 8 end the following: 9 ‘‘SEC. 716. STANDARDS RELATING TO BENEFITS FOR CON- 10 GENITAL ANOMALY OR BIRTH DEFECT. 11 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE TREAT- 12 MENT.— 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 services related to the diag- 17 nosis and treatment of a congenital anomaly or birth 18 defect. 19 ‘‘(2) REQUIREMENTS.—Coverage provided 20 under paragraph (1) shall include any service to 21 functionally improve, repair, or restore any body 22 part that is medically necessary to achieve normal 23 body functioning or appearance, as determined by 24 the treating physician (as defined in section 1861 of 25 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 6 •HR 1379 IH the Social Security Act). Any coverage provided 1 under such paragraph may be subject to coverage 2 limits, such as pre-authorization or pre-certification, 3 as required by the plan or issuer that are no more 4 restrictive than the predominant treatment limita- 5 tions applied to substantially all medical and sur- 6 gical benefits covered by the plan (or coverage). 7 ‘‘(3) TREATMENT DEFINED.— 8 ‘‘(A) IN GENERAL.—Except as provided in 9 subparagraph (B), in this section, the term 10 ‘treatment’ includes patient and outpatient care 11 and services performed to improve or restore 12 body function (or performed to approximate a 13 normal appearance), due to congenital anomaly 14 or birth defect and shall include treatment to 15 any and all missing or abnormal body parts, 16 (including teeth, the oral cavity, and their asso- 17 ciated structures) that would otherwise be pro- 18 vided under the plan or coverage for any other 19 injury and sickness, including— 20 ‘‘(i) inpatient and outpatient care, re- 21 constructive services and procedures, and 22 complications thereof, including prosthetics 23 and appliances; 24 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 7 •HR 1379 IH ‘‘(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 do not materi- 8 ally restore or improve the function of the 9 body part being treated; and 10 ‘‘(iv) procedures for secondary condi- 11 tions and follow-up treatment. 12 ‘‘(B) EXCEPTION.—The term ‘treatment’ 13 shall not include cosmetic surgery performed to 14 reshape normal structures of the body to im- 15 prove appearance or self-esteem. 16 ‘‘(b) NOTICE UNDER GROUP HEALTH PLAN.—The 17 imposition of the requirements of this section shall be 18 treated as a material modification in the terms of the plan 19 described in the last sentence of section 102(a), for pur- 20 poses of assuring notice of such requirements under the 21 plan, except that the summary description required to be 22 provided under the fourth sentence of section 104(b)(1) 23 with respect to such modification shall be provided by not 24 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 8 •HR 1379 IH later than 60 days after the first day of the first plan 1 year in which such requirements apply.’’. 2 (2) TECHNICAL AMENDMENTS.— 3 (A) Section 731(c) of such Act (29 U.S.C. 4 1191(c)) is amended by striking ‘‘section 711’’ 5 and inserting ‘‘sections 711 and 716’’. 6 (B) Section 732(a) of such Act (29 U.S.C. 7 1191a(a)) is amended by striking ‘‘section 711’’ 8 and inserting ‘‘sections 711 and 716’’. 9 (C) The table of contents in section 1 of 10 such Act is amended by inserting after the item 11 relating to section 714 the following new items: 12 ‘‘Sec. 715. Additional market reforms. ‘‘Sec. 716. Standards relating to benefits for congenital anomaly or birth de- fect.’’. (c) INTERNAL REVENUE CODE AMENDMENTS.— 13 (1) IN GENERAL.—Subchapter B of chapter 14 100 of the Internal Revenue Code of 1986 is amend- 15 ed by adding at the end the following: 16 ‘‘SEC. 9816. STANDARDS RELATING TO BENEFITS FOR CON- 17 GENITAL ANOMALY OR BIRTH DEFECT. 18 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE TREAT- 19 MENT.—A group health plan, and a health insurance 20 issuer offering group or individual health insurance cov- 21 erage, shall provide coverage for outpatient and inpatient 22 services related to the diagnosis and treatment of a con- 23 genital anomaly or birth defect. 24 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 9 •HR 1379 IH ‘‘(b) REQUIREMENTS.—Coverage provided under 1 subsection (a) shall include any service to functionally im- 2 prove, repair, or restore any body part that is medically 3 necessary to achieve normal body functioning or appear- 4 ance, as determined by the treating physician (as defined 5 in section 1861 of the Social Security Act). Any coverage 6 provided under such subsection may be subject to coverage 7 limits, such as pre-authorization or pre-certification, as re- 8 quired by the plan or issuer that are no more restrictive 9 than the predominant treatment limitations applied to 10 substantially all medical and surgical benefits covered by 11 the plan (or coverage). 12 ‘‘(c) TREATMENT DEFINED.— 13 ‘‘(1) IN GENERAL.—Except as provided in para- 14 graph (2), in this section, the term ‘treatment’ in- 15 cludes patient and outpatient care and services per- 16 formed to improve or restore body function (or per- 17 formed to approximate a normal appearance), due to 18 congenital anomaly or birth defect and shall include 19 treatment to any and all missing or abnormal body 20 parts, (including teeth, the oral cavity, and their as- 21 sociated structures) that would otherwise be pro- 22 vided under the plan or coverage for any other in- 23 jury and sickness, including— 24 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 10 •HR 1379 IH ‘‘(A) inpatient and outpatient care, recon- 1 structive services and procedures, and complica- 2 tions thereof, including prosthetics and appli- 3 ances; 4 ‘‘(B) adjunctive dental, orthodontic or 5 prosthodontic support from birth until the med- 6 ical or surgical treatment of the defect or 7 anomaly has been completed, including ongoing 8 or subsequent treatment required to maintain 9 function or approximate a normal appearance; 10 ‘‘(C) procedures that do not materially re- 11 store or improve the function of the body part 12 being treated; and 13 ‘‘(D) procedures for secondary conditions 14 and follow-up treatment. 15 ‘‘(2) EXCEPTION.—The term ‘treatment’ shall 16 not include cosmetic surgery performed to reshape 17 normal structures of the body to improve appearance 18 or self-esteem.’’. 19 (2) CLERICAL AMENDMENT.—The table of sec- 20 tions for such subchapter is amended by adding at 21 the end the following new items: 22 ‘‘Sec. 9815. Additional market reforms. ‘‘Sec. 9816. Standards relating to benefits for congenital anomaly or birth de- fect.’’. (d) CLARIFYING AMENDMENT REGARDING APPLICA- 23 TION TO GRANDFATHERED PLANS.—Section 24 VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS 11 •HR 1379 IH 1251(a)(4)(A) of the Patient Protection and Affordable 1 Care Act (42 U.S.C. 18011(a)(4)(A)), is amended by add- 2 ing at the end the following: 3 ‘‘(v) Section 2729 (relating to stand- 4 ards relating to benefits for congenital 5 anomaly or birth defect), as added by sec- 6 tion 2(a) of the Ensuring Lasting Smiles 7 Act.’’. 8 (e) EFFECTIVE DATE.—The amendments made by 9 this section shall apply with respect to group health plans 10 for plan years beginning on or after January 1, 2020, and 11 with respect to health insurance coverage offered, sold, 12 issued, renewed, in effect, or operated in the individual 13 market on or after such date. 14 (f) COORDINATED REGULATIONS.—Section 104(1) of 15 the Health Insurance Portability and Accountability Act 16 of 1996 is amended by striking ‘‘this subtitle (and the 17 amendments made by this subtitle and section 401)’’ and 18 inserting ‘‘the provisions of part 7 of subtitle B of title 19 I of the Employee Retirement Income Security Act of 20 1974, the provisions of parts A and C of title XXVII of 21 the Public Health Service Act, and chapter 100 of the In- 22 ternal Revenue Code of 1986’’. 23 Æ VerDate Sep 11 2014 01:10 Mar 06, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6301 E:\BILLS\H1379.IH H1379 kjohnson on DSK79L0C42 with BILLS