[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 754 Introduced in Senate (IS)]
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117th CONGRESS
1st Session
S. 754
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.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 16, 2021
Ms. Baldwin (for herself, Ms. Ernst, Mr. Brown, Ms. Murkowski, Ms.
Klobuchar, Mr. Marshall, Mrs. Shaheen, Mr. Wicker, Mr. Whitehouse, Mr.
Tillis, Ms. Stabenow, Mr. Cramer, Mr. Van Hollen, Mr. Boozman, Mr.
Peters, Ms. Collins, Mr. Markey, Mrs. Capito, Mr. Booker, Mr. Graham,
Ms. Smith, Mr. Grassley, Ms. Sinema, Mr. Moran, Mr. Murphy, Mr. Daines,
Mr. Blumenthal, Mr. Braun, and Mr. Reed) introduced the following bill;
which was read twice and referred to the Committee on Health,
Education, Labor, and Pensions
_______________________________________________________________________
A BILL
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.
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.--A group health plan under this part shall comply
with the notice requirement under section 714(c) of the Employee
Retirement Income Security Act of 1974 with respect to the requirements
of this section as if such section applied to such plan.''.
(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.--A group health plan under this part shall comply
with the notice requirement under section 714(c) with respect to the
requirements of this section as if such section applied to such
plan.''.
(2) Technical amendments.--
(A) Section 732(a) of such Act (29 U.S.C. 1191a(a))
is amended by striking ``section 711'' and inserting
``sections 711 and 726''.
(B) 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 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 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.--A group health plan under this part shall comply
with the notice requirement under section 714(c) of the Employee
Retirement Income Security Act of 1974 with respect to the requirements
of this section as if such section applied to such plan.''.
(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) Clarifying Amendment Regarding Application to Grandfathered
Plans.--Section 1251(a)(4)(A) of the Patient Protection and Affordable
Care Act (42 U.S.C. 18011(a)(4)(A)), is amended by adding at the end
the following:
``(v) Section 2799A-11 (relating to
standards relating to benefits for congenital
anomaly or birth defect), as added by section
2(a) of the Ensuring Lasting Smiles Act.''.
(f) Effective Date.--The amendments made by this section shall
apply with respect to group health plans for plan years beginning on or
after January 1, 2022, and with respect to health insurance coverage
offered, sold, issued, renewed, in effect, or operated in the
individual market on or after such date.
(g) Coordinated Regulations.--Section 104(1) of the Health
Insurance Portability and Accountability Act of 1996 is amended by
striking ``this subtitle (and the amendments made by this subtitle and
section 401)'' and inserting ``the provisions of part 7 of subtitle B
of title I of the Employee Retirement Income Security Act of 1974, the
provisions of parts A, C, and D of title XXVII of the Public Health
Service Act, and chapter 100 of the Internal Revenue Code of 1986''.
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