Health coverage for congenital anomalies

Summary#

This bill, the Ensuring Lasting Smiles Act, would require many private health plans to cover medical and dental care needed to diagnose and treat congenital anomalies or birth defects that mainly affect the eyes, ears, teeth, mouth, or jaw. The main change is a new legal requirement that group plans and issuers (and plans governed by ERISA and related tax rules) must cover outpatient and inpatient items and services that are medically necessary for these conditions. The bill also requires plans to give notice about the coverage and directs HHS to study access and costs.

Key changes:

• Who must cover: Group health plans and health insurance issuers offering group or individual coverage, including plans subject to ERISA and related tax rules.
• What must be covered: Outpatient and inpatient services to diagnose and treat congenital anomalies affecting eyes, ears, teeth, mouth, or jaw, including reconstructive surgery, follow-up care, and related dental/orthodontic/prosthodontic support from birth until treatment is complete.
• Cost-sharing rule: Any copays, deductibles, or coinsurance for this coverage may not be more restrictive than the plan’s predominant cost-sharing for other medical and surgical benefits.
• Limits: The bill does not require coverage for cosmetic surgery that reshapes normal structures when not medically determined to result from a congenital anomaly.
• Timing and study: Plans must notify participants by January 1, 2026. HHS must report by December 31, 2027, on provider network adequacy and changes in patient out-of-pocket and procedure costs. The coverage rules apply to plan years starting on or after January 1, 2026.

What it means for you#

• People born with facial or oral congenital anomalies (patients and families):

  • Could gain required coverage for surgeries, dental work, orthodontics, prosthetic support, and related follow-up care when a treating physician says it is medically necessary.
  • Dental and orthodontic care tied to treating the congenital condition must be covered from birth until treatment is complete, even if the plan normally excludes or limits dental benefits for other conditions.
  • Cost-sharing for these services (copays, coinsurance, deductibles) must be no tougher than the plan applies to most other medical/surgical benefits.

• Workers and employees with employer plans:

  • Employers offering group health plans subject to the law will need to ensure their plans cover these services and follow the cost-sharing rule starting with plan years on or after January 1, 2026.
  • Plans must notify participants about the new coverage.

• People buying individual market insurance:

  • Health insurance issuers in the individual market must provide the covered benefits described in the bill for eligible congenital anomalies.

• Health care providers (surgeons, dentists, orthodontists, prosthodontists):

  • Services related to congenital anomalies of the eyes, ears, teeth, mouth, or jaw would be covered under more plans when medically necessary, potentially increasing referrals or claims for these providers.

• Insurers and plan administrators:

  • Must update benefit designs, cost-sharing rules, claims processes, and member notices to comply with the new requirements.
  • Must exclude purely cosmetic procedures that are not medically determined to result from a congenital anomaly.

• Medicaid, Medicare, and other public programs:

  • The bill text applies to group health plans and private insurance issuers; it does not change federal Medicaid or Medicare program rules in the text provided. It is unclear from this bill whether those programs would change.

Expenses#

No publicly available information on federal cost estimates or effects on premiums is provided in the bill text or accompanying material.

Possible cost-related effects (inferred from the bill text):

• Insurers and employers may face higher claims for reconstructive, dental, and orthodontic services connected to covered congenital anomalies. This could affect premiums or employer health plan costs.
• Plans will incur administrative costs to change benefit language, notice materials, claims systems, and provider networks.
• The Department of Health and Human Services must conduct a study and report by December 31, 2027; the bill does not state the study’s budget or staffing, so study costs are unspecified.
• The bill requires plans to limit cost-sharing parity, which could increase out-of-pocket coverage for affected patients compared with prior plan terms.

Proponents' View#

• The bill appears intended to ensure that medically necessary reconstructive and related dental care for congenital anomalies of the face and mouth are covered by private health plans.
• Supporters may argue this reduces gaps where dental or orthodontic care needed for medical reasons is currently excluded or limited under many plans.
• The cost-sharing parity rule could be seen as preventing plans from placing higher financial barriers on this type of care than on other medical or surgical care.
• Requiring plan notice aims to make people and families aware of the available coverage.
• The HHS study is designed to check whether provider networks and costs are adequate and to measure changes in out-of-pocket and overall procedure costs after the law takes effect.

Opponents' View#

• One concern is that the bill could raise health plan and employer costs; the bill does not provide an estimate of how much these costs might be or how they would affect premiums.
• The bill relies on a treating physician’s determination of “medically necessary,” but it does not define how disputes about medical necessity are resolved. This may lead to variation in coverage decisions or appeals.
• It is unclear how the cost-sharing parity rule will be enforced and measured across diverse plan structures (for example, plans with differing benefit tiers).
• The bill excludes cosmetic surgery that is not medically determined to result from a congenital anomaly, but it may be unclear in practice what counts as cosmetic versus reconstructive for some procedures.
• The bill does not explicitly change Medicaid or Medicare rules; families relying on those programs may not see changes from this law unless separate action is taken.