119-hr3277

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3277 Introduced in House

    (IH) ]

<DOC>

119th CONGRESS
 1st Session
 H. R. 3277

To provide health insurance benefits for outpatient and inpatient items 
 and services related to the diagnosis and treatment of a congenital 
 anomaly or birth defect.

_______________________________________________________________________

 IN THE HOUSE OF REPRESENTATIVES

 May 8, 2025

Mr. Dunn of Florida (for himself, Ms. Schrier, Mr. Aderholt, Mr. Babin, 
 Ms. Salazar, Mr. Gosar, Mr. Nehls, Mr. Yakym, Ms. Moore of Wisconsin, 
 Mrs. Dingell, Ms. Norton, Ms. Tlaib, Mr. Landsman, Mr. Fields, Ms. 
Bonamici, Mr. Mrvan, Mr. Quigley, Mr. Mannion, Mr. Lynch, Ms. Omar, Ms. 
 Houlahan, Ms. Tokuda, and Mr. Neguse) introduced the following bill; 
 which was referred to the Committee on Energy and Commerce, and in 
 addition to the Committees on Education and Workforce, and Ways and 
 Means, for a period to be subsequently determined by the Speaker, in 
 each case for consideration of such provisions as fall within the 
 jurisdiction of the committee concerned

_______________________________________________________________________

 A BILL

To provide health insurance benefits for outpatient and inpatient 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 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.--Part D of title XXVII of 
the Public Health Service Act (42 U.S.C. 300gg-111 et seq.) is amended 
by adding at the end the following new section:

``

SEC. 2799A-11. COVERAGE OF 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 
 items and services related to the diagnosis and treatment of a 
 congenital anomaly or birth defect that primarily impacts the 
 appearance or function of the eyes, ears, teeth, mouth, or jaw, 
 consistent with paragraphs

    (2) and

    (3) .
 ``

    (2) Financial requirements.--Any coverage provided under 
 paragraph

    (1) under a group health plan or group or individual 
 health insurance coverage may be subject to cost-sharing 
 requirements (such as coinsurance, copayments, and 
 deductibles), as required by the plan or issuer offering such 
 coverage, that are no more restrictive than the predominant 
 cost-sharing requirements applied to substantially all other 
 medical and surgical benefits covered by the plan or coverage.
 ``

    (3) Applicable items and services.--
 ``
        (A) In general.--Except as provided in 
 subparagraph
        (B) , the items and services required under 
 paragraph

    (1) to be covered by a group health plan or 
 group or individual health insurance coverage offered 
 by a health insurance issuer include--
 ``
            (i) any item or service to improve, 
 repair, or restore any body part to achieve 
 normal body functioning or appearance, or 
 performed to approximate a normal appearance, 
 as determined medically necessary by the 
 treating physician (as defined in 

section 1861

    (r) of the Social Security Act), on account 
 of a congenital anomaly or birth defect that 
 primarily impacts the appearance or function of 
 the eyes, ears, teeth, mouth, or jaw; and
 ``
            (ii) any treatment or diagnostic service 
 with respect to any and all missing or abnormal 
 body parts (including teeth, the oral cavity, 
 and their associated structures), as determined 
 medically necessary by the treating physician 
 (as defined in 

section 1861

    (r) of the Social 
 Security Act), including--
 ``
            (I) reconstructive services and 
 procedures, and items and services 
 related to any complications arising 
 from such services and procedures;
 ``
            (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, 
 notwithstanding any exclusions, 
 limitations, or restrictions under the 
 plan or health insurance coverage on 
 coverage of dental, orthodontic, or 
 prosthodontic items and services 
 arising from other injuries or 
 sicknesses; and
 ``
            (III) items and services related 
 to secondary conditions and follow-up 
 treatment associated with the 
 underlying congenital anomaly or birth 
 defect.
 ``
        (B) Exception.--The items and services required 
 under this subsection to be covered by a group health 
 plan or health insurance issuer offering group or 
 individual health insurance coverage shall not include 
 cosmetic surgery performed to reshape normal structures 
 of the body to improve appearance or self-esteem, if 
 such items and services are not furnished as a result 
 of a medical determination of a congenital anomaly or 
 birth defect.
 ``

    (b) Notice.--Beginning not later January 1, 2026, a group health 
plan or health insurance issuer offering group or individual health 
insurance coverage shall provide notice to each participant and 
beneficiary under such plan or coverage regarding the coverage required 
by this section in any documents describing services, in accordance 
with any regulations promulgated by the Secretary.
 ``
            (c) === Definition. ===
-In this section, the term `congenital anomaly or 
birth defect' means a structural or functional anomaly that occurs 
during intrauterine life, develops prenatally, and may be identified 
before birth, at birth, or later in life, and which may--
 ``

    (1) be caused by genetic or chromosomal disorders, 
 embryotoxic or teratogenic environmental factors, nutrient 
 deficiency, multifactorial inheritance, or be of an unknown 
 cause;
 ``

    (2) manifest as abnormal anatomical structures;
 ``

    (3) manifest as physical, sensory, or cognitive 
 functional disabilities;
 ``

    (4) manifest as syndromes, diseases, or other health 
 problems; and
 ``

    (5) manifest as singular anomalies or in combination 
 prenatally, at birth, or later in life.''.

    (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. 726. COVERAGE OF 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 health insurance coverage, 
 shall provide coverage for outpatient and inpatient items and 
 services related to the diagnosis and treatment of a congenital 
 anomaly or birth defect that primarily impacts the appearance 
 or function of the eyes, ears, teeth, mouth, or jaw, consistent 
 with paragraphs

    (2) and

    (3) .
 ``

    (2) Financial requirements.--Any coverage provided under 
 paragraph

    (1) under a group health plan or group health 
 insurance coverage offered by a health insurance issuer may be 
 subject to cost-sharing requirements (such as coinsurance, 
 copayments, and deductibles), as required by the plan or issuer 
 offering such coverage, that are no more restrictive than the 
 predominant cost-sharing requirements applied to substantially 
 all other medical and surgical benefits covered by the plan or 
 coverage.
 ``

    (3) Applicable items and services.--
 ``
        (A) In general.--Except as provided in 
 subparagraph
        (B) , the items and services required under 
 paragraph

    (1) to be covered by a group health plan or 
 group health insurance coverage offered by a health 
 insurance issuer include--
 ``
            (i) any item or service to improve, 
 repair, or restore any body part to achieve 
 normal body functioning or appearance, or 
 performed to approximate a normal appearance, 
 as determined medically necessary by the 
 treating physician (as defined in 

section 1861

    (r) of the Social Security Act), on account 
 of a congenital anomaly or birth defect that 
 primarily impacts the appearance or function of 
 the eyes, ears, teeth, mouth, or jaw; and
 ``
            (ii) any treatment or diagnostic service 
 with respect to any and all missing or abnormal 
 body parts (including teeth, the oral cavity, 
 and their associated structures), as determined 
 medically necessary by the treating physician 
 (as defined in 

section 1861

    (r) of the Social 
 Security Act), including--
 ``
            (I) reconstructive services and 
 procedures, and items and services 
 related to any complications arising 
 from such services and procedures;
 ``
            (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, 
 notwithstanding any exclusions, 
 limitations, or restrictions under the 
 plan or health insurance coverage on 
 coverage of dental, orthodontic, or 
 prosthodontic items and services 
 arising from other injuries or 
 sicknesses; and
 ``
            (III) items and services related 
 to secondary conditions and follow-up 
 treatment associated with the 
 underlying congenital anomaly or birth 
 defect.
 ``
        (B) Exception.--The items and services required 
 under this subsection to be covered by a group health 
 plan or health insurance issuer offering group health 
 insurance coverage shall not include cosmetic surgery 
 performed to reshape normal structures of the body to 
 improve appearance or self-esteem, if such items and 
 services are not furnished as a result of a medical 
 determination of a congenital anomaly or birth defect.
 ``

    (b) Notice.--Beginning not later than January 1, 2026, a group 
health plan or health insurance issuer offering group health insurance 
coverage shall provide notice to each participant and beneficiary under 
such plan or coverage regarding the coverage required by this section, 
in any documents describing services, in accordance with any 
regulations promulgated by the Secretary.
 ``
            (c) === Definition. ===
-In this section, the term `congenital anomaly or 
birth defect' means a structural or functional anomaly that occurs 
during intrauterine life, develops prenatally, and may be identified 
before birth, at birth, or later in life, and which may--
 ``

    (1) be caused by genetic or chromosomal disorders, 
 embryotoxic or teratogenic environmental factors, nutrient 
 deficiency, multifactorial inheritance, or be of an unknown 
 cause;
 ``

    (2) manifest as abnormal anatomical structures;
 ``

    (3) manifest as physical, sensory, or cognitive 
 functional disabilities;
 ``

    (4) manifest as syndromes, diseases, or other health 
 problems; and
 ``

    (5) manifest as singular anomalies or in combination 
 prenatally, at birth, or later in life.''.

    (2) Technical amendments.--
        (A) Section 732

    (a) of such Act (29 U.S.C. 1191a

    (a) ) 
 is amended by striking ``

section 711'' and inserting 
 ``sections 711 and 726''.
        (B) The table of contents in 

section 1 of such Act 
 is amended by inserting after the item relating to 
 

section 725 the following new item:

``

Sec. 726. Coverage of 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 is amended by adding at the end 
 the following:

``

SEC. 9826. COVERAGE OF CONGENITAL ANOMALY OR BIRTH DEFECT.

 ``

    (a) Requirements for Care and Reconstructive Treatment.--
 ``

    (1) In general.--A group health plan shall provide 
 coverage for outpatient and inpatient items and services 
 related to the diagnosis and treatment of a congenital anomaly 
 or birth defect that primarily impacts the appearance or 
 function of the eyes, ears, teeth, mouth, or jaw, consistent 
 with paragraphs

    (2) and

    (3) .
 ``

    (2) Financial requirements.--Any coverage provided under 
 paragraph

    (1) under a group health plan may be subject to cost-
 sharing requirements (such as coinsurance, copayments, and 
 deductibles), as required by the plan, that are no more 
 restrictive than the predominant cost-sharing requirements 
 applied to substantially all other medical and surgical 
 benefits covered by the plan.
 ``

    (3) Applicable items and services.--
 ``
        (A) In general.--Except as provided in 
 subparagraph
        (B) , the items and services required under 
 paragraph

    (1) to be covered by a group health plan 
 include--
 ``
            (i) any item or service to improve, 
 repair, or restore any body part to achieve 
 normal body functioning or appearance, or 
 performed to approximate a normal appearance, 
 as determined medically necessary by the 
 treating physician (as defined in 

section 1861

    (r) of the Social Security Act), on account 
 of a congenital anomaly or birth defect that 
 primarily impacts the appearance or function of 
 the eyes, ears, teeth, mouth, or jaw; and
 ``
            (ii) any treatment or diagnostic service 
 with respect to any and all missing or abnormal 
 body parts (including teeth, the oral cavity, 
 and their associated structures), as determined 
 medically necessary by the treating physician 
 (as defined in 

section 1861

    (r) of the Social 
 Security Act), including--
 ``
            (I) reconstructive services and 
 procedures, and items and services 
 related to any complications arising 
 from such services and procedures;
 ``
            (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, 
 notwithstanding any exclusions, 
 limitations, or restrictions under the 
 plan on coverage of dental, 
 orthodontic, or prosthodontic items and 
 services arising from other injuries or 
 sicknesses; and
 ``
            (III) items and services related 
 to secondary conditions and follow-up 
 treatment associated with the 
 underlying congenital anomaly or birth 
 defect.
 ``
        (B) Exception.--The items and services required 
 under this subsection to be covered by a group health 
 plan shall not include cosmetic surgery performed to 
 reshape normal structures of the body to improve 
 appearance or self-esteem, if such items and services 
 are not furnished as a result of a medical 
 determination of a congenital anomaly or birth defect.
 ``

    (b) Notice.--Beginning not later January 1, 2026, a group health 
plan shall provide notice to each participant and beneficiary under 
such plan or coverage regarding the coverage required by this section 
in any documents describing services, in accordance with any 
regulations promulgated by the Secretary.
 ``
            (c) === Definition. ===
-In this section, the term `congenital anomaly or 
birth defect' means a structural or functional anomaly that occurs 
during intrauterine life, develops prenatally, and may be identified 
before birth, at birth, or later in life, and which may--
 ``

    (1) be caused by genetic or chromosomal disorders, 
 embryotoxic or teratogenic environmental factors, nutrient 
 deficiency, multifactorial inheritance, or be of an unknown 
 cause;
 ``

    (2) manifest as abnormal anatomical structures;
 ``

    (3) manifest as physical, sensory, or cognitive 
 functional disabilities;
 ``

    (4) manifest as syndromes, diseases, or other health 
 problems; and
 ``

    (5) manifest as singular anomalies or in combination 
 prenatally, at birth, or later in life.''.

    (2) Clerical amendment.--The table of sections for such 
 subchapter is amended by adding at the end the following new 
 item:

``

Sec. 9826. Coverage of congenital anomaly or birth defect.''.
            (d) Study and Report on Network Adequacy.--The Secretary of Health 
and Human Services shall conduct a study, and not later than December 
31, 2027, submit a report to Congress, on the matters relating to 
access of services for coverage of outpatient and inpatient items and 
services related to the diagnosis and treatment of a congenital anomaly 
or birth defect that primarily impacts the appearance or function of 
the eyes, ears, teeth, mouth, or jaw. Such study and report shall--

    (1) evaluate the sufficiency and accessibility of networks 
 of providers that perform services related to the diagnosis and 
 treatment of such congenital anomalies and birth defects under 
 group health plans and group and individual health insurance 
 coverage (as such terms are defined in 

section 2791 of the 
 Public Health Service Act (42 U.S.C. 300gg-91)); and

    (2) assess any change in out-of-pocket costs for patients, 
 by procedure type, resulting from the coverage requirements 
 under sections 2799A-11 of the Public Health Service Act, 726 
 of the Employee Retirement Income Security Act of 1974, and 
 9826 of the Internal Revenue Code of 1986, as added by this 
 section, and any change in the overall procedure cost for such 
 services.

    (e) Effective Date.--The amendments made by subsections

    (a) ,

    (b) , 
and
            (c) shall apply with respect to plan years beginning on or after 
January 1, 2026.
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