Ensuring Lasting Smiles Act
Floor Speech
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Ms. ESHOO. Madam Speaker, I move to suspend the rules and pass the bill (H.R. 1916) 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, as amended.
The Clerk read the title of the bill.
The text of the bill is as follows: H.R. 1916
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. STANDARDS RELATING TO BENEFITS FOR 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.
``(2) Requirements.--
``(A) In general.--Coverage provided under paragraph (1) shall include any medically necessary item or service to functionally improve, repair, or restore any body part to achieve normal body functioning or appearance, as determined by the treating physician (as defined in section 1861(r) of the Social Security Act), due to congenital anomaly or birth defect.
``(B) Financial requirements and treatment requirements.-- Any coverage provided under paragraph (1) under a group health plan or individual or group health insurance coverage offered by a health insurance issuer may be subject to coverage limits (such as medical necessity, pre- authorization, or pre-certification) and cost-sharing requirements (such as coinsurance, copayments, and deductibles), as required by the plan or issuer, that are no more restrictive than the predominant coverage limits and cost-sharing requirements, respectively, applied to substantially all medical and surgical benefits covered by the plan (or coverage).
``(3) Treatment defined.--In this section:
``(A) In general.--Except as provided in subparagraph (B), the term `treatment' includes, with respect to a group health plan or group or individual health insurance coverage offered by a health insurance issuer, inpatient and outpatient items and services performed to improve, repair, or restore bodily function (or performed to approximate a normal appearance), due to a congenital anomaly or birth defect, and includes treatment to any and all missing or abnormal body parts (including teeth, the oral cavity, and their associated structures) that would otherwise be provided under the plan or coverage for any other injury or sickness, including--
``(i) any items or services, including inpatient and outpatient care, reconstructive services and procedures, and complications thereof;
``(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;
``(iii) procedures that materially improve, repair, or restore bodily function; and
``(iv) procedures for secondary conditions and follow-up treatment associated with the underlying congenital anomaly or birth defect.
``(B) Exception.--The term `treatment' shall not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.
``(b) Notice.--Not later than one year after the date of the enactment of this section and annually thereafter, a group health plan, and a health insurance issuer offering group or individual health insurance coverage, shall, in accordance with regulations or guidance issued by the Secretary, provide to each enrollee under such plan or coverage a written description of the terms of this section. Such description shall be in language which is understandable to the typical enrollee.''.
(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. STANDARDS RELATING TO BENEFITS FOR 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.
``(2) Requirements.--
``(A) In general.--Coverage provided under paragraph (1) shall include any medically necessary item or service to functionally improve, repair, or restore any body part to achieve normal body functioning or appearance, as determined by the treating physician (as defined in section 1861(r) of the Social Security Act), due to congenital anomaly or birth defect.
``(B) Financial requirements and treatment 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 coverage limits (such as medical necessity, pre-authorization, or pre- certification) and cost-sharing requirements (such as coinsurance, copayments, and deductibles), as required by the plan or issuer, that are no more restrictive than the predominant coverage limits and cost-sharing requirements, respectively, applied to substantially all medical and surgical benefits covered by the plan (or coverage).
``(3) Treatment defined.--In this section:
``(A) In general.--Except as provided in subparagraph (B), the term `treatment' includes, with respect to a group health plan or group health insurance coverage offered by a health insurance issuer, inpatient and outpatient items and services performed to improve, repair, or restore bodily function (or performed to approximate a normal appearance), due to a congenital anomaly or birth defect, and includes treatment to any and all missing or abnormal body parts (including teeth, the oral cavity, and their associated structures) that would otherwise be provided under the plan or coverage for any other injury or sickness, including--
``(i) any items or services, including inpatient and outpatient care, reconstructive services and procedures, and complications thereof;
``(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;
``(iii) procedures that materially improve, repair, or restore bodily function; and
``(iv) procedures for secondary conditions and follow-up treatment associated with the underlying congenital anomaly or birth defect.
``(B) Exception.--The term `treatment' shall not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.
``(b) Notice.--Not later than one year after the date of the enactment of this section and annually thereafter, a group health plan, and a health insurance issuer offering group health insurance coverage, shall, in accordance with regulations or guidance issued by the Secretary, provide to each participant or beneficiary under such plan or coverage a written description of the terms of this section. Such description shall be in language which is understandable to the typical participant or beneficiary.''.
(2) Technical amendment.--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. Standards relating to benefits for congential 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. STANDARDS RELATING TO BENEFITS FOR 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.
``(2) Requirements.--
``(A) In general.--Coverage provided under paragraph (1) shall include any medically necessary item or service to functionally improve, repair, or restore any body part to achieve normal body functioning or appearance, as determined by the treating physician (as defined in section 1861(r) of the Social Security Act), due to congenital anomaly or birth defect.
``(B) Financial requirements and treatment requirements.-- Any coverage provided under paragraph (1) under a group health plan may be subject to coverage limits (such as medical necessity, pre-authorization, or pre-certification) and cost-sharing requirements (such as coinsurance, copayments, and deductibles), as required by the plan, that are no more restrictive than the predominant coverage limits and cost-sharing requirements, respectively, applied to substantially all medical and surgical benefits covered by the plan.
``(3) Treatment defined.--In this section:
``(A) In general.--Except as provided in subparagraph (B), the term `treatment' includes, with respect to a group health plan, inpatient and outpatient items and services performed to improve, repair, or restore bodily function (or performed to approximate a normal appearance), due to a congenital anomaly or birth defect, and includes treatment to any and all missing or abnormal body parts (including teeth, the oral cavity, and their associated structures) that would otherwise be provided under the plan for any other injury or sickness, including--
``(i) any items or services, including inpatient and outpatient care, reconstructive services and procedures, and complications thereof;
``(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;
``(iii) procedures that materially improve, repair, or restore bodily function; and
``(iv) procedures for secondary conditions and follow-up treatment associated with the underlying congenital anomaly or birth defect.
``(B) Exception.--The term `treatment' shall not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.
``(b) Notice.--Not later than one year after the date of the enactment of this section and annually thereafter, a group health plan shall, in accordance with regulations or guidance issued by the Secretary, provide to each enrollee under such plan a written description of the terms of this section. Such description shall be in language which is understandable to the typical enrollee.''.
(2) Clerical amendment.--The table of sections for such subchapter is amended by adding at the end the following new item: ``Sec. 9826. Standards relating to benefits for congenital anomaly or birth defect.''.
(d) Rule of Construction.--A group health plan or health insurance issuer shall provide the benefits described in section 2799A-11 of the Public Health Service Act (as added by subsection (a)), section 726 of the Employee Retirement Income Security Act of 1974 (as added by subsection (b)), and section 9826 of the Internal Revenue Code of 1986 (as added by subsection (c)) under the terms of such plan or health insurance coverage offered by such issuer.
(e) Effective Date.--The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2024. SEC. 3. DETERMINATION OF BUDGETARY EFFECTS.
The budgetary effects of this Act, for the purpose of complying with the Statutory Pay-As-You-Go Act of 2010, shall be determined by reference to the latest statement titled ``Budgetary Effects of PAYGO Legislation'' for this Act, submitted for printing in the Congressional Record by the Chairman of the House Budget Committee, provided that such statement has been submitted prior to the vote on passage.
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Ms. ESHOO. 1916.
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Ms. ESHOO. Madam Speaker, I yield myself such time as I may consume.
Madam Speaker, I rise in full support of H.R. 1916, the Ensuring Lasting Smiles Act. On behalf of the 4 percent of American children born annually with congenital anomalies or birth defects, I am very proud to sponsor this much-needed legislation.
This bill will ensure that health plans do not deny or delay medically necessary treatment of congenital anomalies. In many cases, coverage for well-known anomalies, like heart defects or spina bifida, is already the standard. But for babies who have oral defects such as cleft palates, skeletal defects, congenital cataracts, or hearing defects, insurance companies have systematically denied or delayed medically necessary treatments.
I became a sponsor of this legislation after Kevin Koser testified at our Health Subcommittee, which you are a member of, Madam Speaker, about his beautiful son, Kannon. He shared with the subcommittee how Kannon asked Santa Claus for teeth so he could ``chomp big bites'' of food.
I was really shaken by that and by the fact that in our country, such a rich and great country as America, we would put treatment that allows a child to eat out of reach because of insurance red tape.
A baby named Rosie in my congressional district is one of the 1,300 babies born in the United States each year with congenital cataracts. In just a few months, her family spent over $4,000 out of pocket on contact lenses for her. Without these lenses, babies like Rosie are blind, and they have no chance of ever developing normal vision.
These stories are repeated across our country every single day, but today is the day that we can begin to change that. This legislation is one of the most popular bills in the House, with 316 bipartisan cosponsors, including more than half of the Republican Conference.
The time has come for this important, popular, and much-needed bill to finally pass the House of Representatives.
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Ms. ESHOO. Madam Speaker, the bill that we are taking up today was passed by the Energy and Commerce Committee. It hasn't changed. The gentleman, Mr. Griffith, had an amendment. He withdrew it. He had the opportunity, but he withdrew it.
Madam Speaker, I yield such time as he may consume to the gentleman from New Jersey (Mr. Pallone), the chairman of the Energy and Commerce Committee.
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Ms. ESHOO. Madam Speaker, I yield myself the balance of my time.
I thank the gentleman for his kind comments about me. I think that there are a couple of important points to be made. And that is that CBO estimates that insurers will respond to this bill by raising premiums by less than 0.1 percent. What CBO does not score are the savings from providing this needed medical care because that medical care goes on and on and on. And the costs to families are exorbitant.
As I said earlier today, I think this is a very good bill. I acknowledge all the advocates from all over the country that worked so hard to bring us to this moment.
Madam Speaker, I look forward to the vote today on this bill that has been with us since 2020, and I yield back the balance of my time.
Ms. JACKSON LEE. Madam Speaker, I rise in strong support of H.R. 1916, the Ensuring Lasting Smiles Act.
The purpose of this bill is to provide health insurance benefits for outpatient and inpatient items and services related to the diagnosis and treatment of congenital anomalies and birth defects.
This bill requires private health insurance plans to cover the diagnosis and treatment of birth defects, congenital disorders, or congenital malformations, conditions developed prenatally and may be identified before or at birth, or later in life.
The coverage must include services and items that functionally improve, repair, or restore any body part that is medically necessary for normal bodily functions or appearance, as determined by the treating physician.
This bill protects patients against increased insurance premiums by clearly specifying that coverage for these treatments may be subjected only to the same limits that apply to other injuries or sicknesses without imposing any greater financial responsibilities on the patient or family.
This legislation would also close an insurance coverage loophole for people born with congenital anomalies who need complex oral restorative care.
It would ensure that health plans cover medically necessary services related to a patient's anomaly or birth defect, including any serious dental and oral-related procedures that are necessary to maintaining health and overall function.
Insurance companies usually cover the preliminary procedures to treat congenital anomalies, but often deny and delay follow-up reconstructive procedures.
Denial or delay of these reconstructive procedures could lead to long-term physical and psychological injuries.
Insurance companies claim these follow up procedures are only cosmetic in nature, which then places a significant burden on patients and their families.
It is relatively rare for a child with a congenital deformity or developmental anomaly to undergo just one procedure that corrects all the associated health implications the first time.
On average, these children can expect anywhere from three to five surgical procedures and many more treatments before achieving structural normalcy and function in the affected body parts.
These families are then forced to pay huge out-of-pocket costs for treatment coverage or, in worst case scenarios, terminate treatment.
For example, people born with ectodermal dysplasia's are often unable to properly develop teeth.
Their teeth may be missing, completely absent, have defective enamel or be shaped differently.
If the teeth are not repaired or replaced, these individuals could have chewing, swallowing, digestive, speech and self-esteem issues.
Someone born with ectodermal dysplasia spends a significant amount of money on necessary medical and dental care throughout their lifetime.
This amount of money can become so excessive that families may have no option other than selling their cars, remortgaging their homes, and foregoing a college education to afford medically necessary dental care.
Far more families simply go without care because they can't afford it.
Dental care is also subject to a double-standard, while some individuals who lose their teeth due to an accident receive dental benefits under the existing statutes, those who are missing teeth due to ectodermal dysplasias, a medical condition they were born with, do not receive these same dental benefits.
The Ensuring Lasting Smiles Act would fix this.
This bill would help more families than those affected by the ectodermal dysplasias. It would cover a broad range of congenital anomalies.
Many people born with congenital anomalies suffer from severe oral defects such as:
Cleft lip or palate
Hypodontia
Enamel hypoplasia
Skeletal defects like craniosynostosis
Vision defects like congenital cataracts or aphakia
Hearing defects like microtia
Other loss of bodily functions
According to the Center for Disease Control and Prevention (CDC), one in 33 babies in the United States is born with a congenital anomaly.
Of those 120,000 children born annually with birth defects, approximately 40,000 require reconstructive surgery.
Medical professionals and surgeons are fortunately able to correct many of these problems, however some insurance companies deny access to care by labeling the procedures as ``cosmetic'' or ``non-functional'' in nature.
Too many children born with congenital anomalies are denied coverage despite the long-term harm of such conditions.
The Ensuring Lasting Smiles Act would address delays and denials in coverage and guarantee that children suffering from birth defects and anomalies get the treatment they need.
I ask my colleagues to join me in voting for H.R. 1916 because this law guarantees the payment of health insurance benefits for necessary medical care and treatment due to any congenital anomaly.
These families deserve to see the day when they no longer have to fight for coverage of medically necessary treatments and their children and loved ones receive the treatments they desperately need and deserve.
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