Ensuring Lasting Smiles Act

Summary#

This bill, the Ensuring Lasting Smiles Act, would require most private 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. Covered services include medically necessary reconstructive care, treatment for missing or abnormal parts (including teeth and oral structures), related complications, and dental/orthodontic/prosthodontic support from birth until the medical or surgical treatment is complete. Cosmetic surgery that reshapes normal structures to improve appearance or self‑esteem is not required to be covered if it is not medically related to a congenital anomaly.

The bill adds parallel requirements to the Public Health Service Act, the Employee Retirement Income Security Act (ERISA), and the Internal Revenue Code. Plans may apply cost‑sharing (like copays, coinsurance, or deductibles), but those cost‑sharing rules cannot be more restrictive than the predominant cost‑sharing applied to substantially all other medical and surgical benefits in the plan. Plans and issuers must give notice about the coverage starting January 1, 2026. The bill also directs the Secretary of Health and Human Services to study network adequacy and changes in out‑of‑pocket and procedure costs and report to Congress by December 31, 2027. The coverage rules apply to plan years beginning on or after January 1, 2026.

What it means for you#

• If you have a group health plan or buy individual or group coverage from an issuer, your plan would need to cover medically necessary care for congenital anomalies that mainly affect the eyes, ears, teeth, mouth, or jaw.
• Coverage can include surgeries, reconstructive procedures, follow‑up care, and dental or orthodontic support tied to treatment of the defect.
• Your plan can still require cost‑sharing, but those requirements cannot be more restrictive than the plan’s usual medical and surgical cost‑sharing.
• Plans and issuers must provide notice about this coverage to participants and beneficiaries beginning January 1, 2026.
• The law’s coverage rules would take effect for plan years starting on or after January 1, 2026.

Expenses#

No publicly available information on overall federal or private sector costs is included in the bill text. The bill does require a study and report by HHS, due December 31, 2027, that will assess how the coverage requirements affect access to providers, changes in out‑of‑pocket costs by procedure type, and changes in overall procedure costs. The bill allows plans to apply cost‑sharing but requires that cost‑sharing not be more restrictive than the plan’s predominant medical and surgical cost‑sharing.

Proponents' View#

No publicly available information in the bill text or provided metadata states proponents’ listed reasons or arguments for the bill.

Opponents' View#

No publicly available information in the bill text or provided metadata states opponents’ listed reasons or arguments against the bill.