Ensuring Lasting Smiles Act
The Ensuring Lasting Smiles Act would require group health plans and health insurance issuers to cover outpatient and inpatient items and services for diagnosing and treating congenital anomalies or birth defects that mainly affect the appearance or function of the eyes, ears, teeth, mouth, or jaw. This coverage would include reconstructive services, follow-up care, and associated dental/orthodontic/prosthodontic support from birth until the defect is treated and function or appearance is stabilized, with the exception of cosmetic surgeries not medically tied to a congenital condition. The bill would apply across major health coverage frameworks (Public Health Service Act, ERISA, and the Internal Revenue Code), mandate notice to enrollees about the coverage, define congenital anomaly/birth defect broadly, and require a study on network adequacy and out-of-pocket costs. The protections would take effect for plan years beginning on or after January 1, 2026.
Key Points
- 1Scope of coverage: Requires group health plans and health insurance issuers to cover outpatient and inpatient services for diagnosing and treating congenital anomalies or birth defects that affect appearance or function of the eyes, ears, teeth, mouth, or jaw.
- 2Included services: Covers items and services to improve, repair, or restore body parts and those related to missing or abnormal parts, including reconstructive procedures, adjunctive dental/orthodontic/prosthodontic support from birth until treatment is complete, and follow-up care for related conditions.
- 3Cost-sharing: Coverage may include cost-sharing (coinsurance, copays, deductibles) but not be more restrictive than the predominant cost-sharing for other medical/surgical benefits.
- 4Cosmetic surgery exception: Cosmetic procedures not medically determined by a congenital anomaly or birth defect are not required to be covered.
- 5Notice to enrollees: Beginning no later than January 1, 2026, plans/issuers must inform participants/beneficiaries about this coverage.
- 6Definitions and scope: Defines congenital anomaly or birth defect broadly and links coverage to medical necessity as determined by the treating physician.
- 7Parallel statutory tracks: The same requirements would apply under PHSA (Public Health Service Act), ERISA, and the Internal Revenue Code, with corresponding amendments.
- 8Study and report: The Secretary of Health and Human Services must study network adequacy and out-of-pocket costs related to these coverages, with a report due by December 31, 2027.
- 9Effective date: The new coverage provisions apply to plan years beginning on or after January 1, 2026.