Ensuring Lasting Smiles Act
The Ensuring Lasting Smiles Act would create a federal mandate to require health plans and health insurers to cover outpatient and inpatient items and services related to the diagnosis and treatment of congenital anomalies or birth defects that mainly affect the appearance or function of the eyes, ears, teeth, mouth, or jaw. Coverage would include reconstructive and diagnostic services, as well as ongoing dental, orthodontic, or prosthodontic support from birth until treatment is completed, plus follow-up care. Cosmetic surgery not tied to a medical determination of a congenital anomaly would be excluded. The bill sets a standard for cost-sharing that cannot be more restrictive than the plan’s predominant cost-sharing for other medical/surgical benefits, and it requires notices to participants about the coverage starting in 2026. It also creates a study on network adequacy and cost impacts, with amendments to the Public Health Service Act, ERISA, and the Internal Revenue Code, and applies to plan years beginning on or after January 1, 2026.
Key Points
- 1New federal coverage mandate for congenital anomalies/birth defects affecting appearance or function of eyes, ears, teeth, mouth, or jaw. Applies to group health plans and health insurance issuers offering group or individual coverage; standard is medical necessity as determined by the treating physician.
- 2Covered items and services include: reconstructive services, diagnostic services for missing/abnormal parts, adjunctive dental/orthodontic/prosthodontic support from birth until treatment completion, ongoing maintenance, and follow-up care related to the underlying defect; cost-sharing cannot be more restrictive than the plan’s standard for other medical/surgical benefits.
- 3Cosmetic surgery exception: cosmetic procedures not medically necessitated by a congenital anomaly remain excluded.
- 4Notice requirement: starting by January 1, 2026, plans must notify participants/beneficiaries about the coverage in service descriptions.
- 5Study and reporting: HHS must study provider network adequacy and out-of-pocket costs related to these new coverage rules, with findings due by December 31, 2027.
- 6Effective date: the new coverage requirements apply to plan years beginning on or after January 1, 2026; accompanied by parallel amendments to ERISA and the Internal Revenue Code.