[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 7702 Introduced in House (IH)]
<DOC>
117th CONGRESS
2d Session
H. R. 7702
To provide health insurance benefits for outpatient and inpatient items
and services related to the diagnosis and treatment of a craniofacial,
oral, or maxillofacial congenital anomaly or birth defect.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 10, 2022
Mr. Dunn (for himself and Mr. Griffith) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committees on Education and Labor, 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 craniofacial,
oral, or maxillofacial 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 CRANIOFACIAL, ORAL, OR MAXILLOFACIAL 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 CRANIOFACIAL, ORAL,
OR MAXILLOFACIAL 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
craniofacial, oral, or maxillofacial 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 craniofacial, oral, or
maxillofacial 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 craniofacial, oral, or
maxillofacial 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 craniofacial, oral, or maxillofacial
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 CRANIOFACIAL, ORAL, OR
MAXILLOFACIAL 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
craniofacial, oral, or maxillofacial 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 craniofacial, oral, or
maxillofacial 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 craniofacial, oral, or
maxillofacial 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 craniofacial, oral, or maxillofacial
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 craniofacial, oral, or
maxillofacial 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. STANDARDS RELATING TO BENEFITS FOR CRANIOFACIAL, ORAL, OR
MAXILLOFACIAL 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 craniofacial, oral,
or maxillofacial 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 craniofacial, oral, or
maxillofacial 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
craniofacial, oral, or maxillofacial 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 craniofacial, oral, or maxillofacial
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 craniofacial, oral, or
maxillofacial 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.
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