HR3277-119

What This Bill Does

The Ensuring Lasting Smiles Act adds parallel coverage mandates to the Public Health Service Act, ERISA, and the Internal Revenue Code. Group health plans and group or individual health insurance issuers must cover outpatient and inpatient diagnosis and treatment for congenital anomalies or birth defects that primarily affect the appearance or function of the eyes, ears, teeth, mouth, or jaw. Required coverage includes medically necessary repair, restoration, reconstructive procedures, treatment for missing or abnormal body parts including teeth and oral structures, adjunctive dental, orthodontic, and prosthodontic support from birth until treatment is complete, ongoing treatment to maintain function or approximate normal appearance, secondary conditions, and follow-up care. Cost sharing may be no more restrictive than predominant cost sharing for medical and surgical benefits. Cosmetic surgery to reshape normal structures for appearance or self-esteem is excluded. Plans must provide notices by January 1, 2026, and HHS must report by December 31, 2027 on provider network sufficiency, out-of-pocket cost changes, and overall procedure costs.

Who Benefits and How

Children with congenital anomalies benefit because medically necessary dental, orthodontic, prosthodontic, reconstructive, and follow-up care must be covered. Families of affected patients benefit from cost-sharing protections and fewer dental or orthodontic exclusions for birth-defect treatment. Craniofacial care providers benefit from clearer coverage for services involving eyes, ears, teeth, mouth, and jaw conditions. Patient advocacy organizations benefit from a federal mandate that treats congenital anomaly treatment as medical care rather than cosmetic care.

Who Bears the Burden and How

Health insurance issuers must cover required services and apply no more restrictive cost sharing than for other medical and surgical benefits. Employer group health plans must update plan documents and notices by January 1, 2026. HHS insurance staff must oversee the coverage rules and submit the 2027 access and cost report to Congress. Plan sponsors may bear higher claims costs for reconstructive, dental, orthodontic, prosthodontic, secondary, and follow-up care.

Key Provisions

• Requires coverage of diagnosis and treatment for congenital anomalies or birth defects affecting eyes, ears, teeth, mouth, or jaw.
• Provides coverage for reconstructive, dental, orthodontic, prosthodontic, secondary, and follow-up services deemed medically necessary.
• Limits cost sharing to no more restrictive than predominant medical and surgical benefit cost sharing.
• Requires plan notices by January 1, 2026 and an HHS report by December 31, 2027 on access and costs.