Ensuring Lasting Smiles Act
- Sponsor
- Sen. Baldwin, Tammy [D-WI]
- Committees
- Health, Education, Labor, and Pensions Committee (primary)
- Last action
- Mar 19, 2026
Bottom line
The bill requires health insurance plans to cover medically necessary reconstructive and adjunctive treatments for congenital anomalies affecting specific facial and oral structures, aiming to ensure comprehensive care for affected individuals.
What it actually does
This bill mandates that group health plans and health insurance issuers provide coverage for outpatient and inpatient services related to the diagnosis and treatment of congenital anomalies or birth defects that primarily impact the appearance or function of the eyes, ears, teeth, mouth, or jaw. It specifies that coverage must include reconstructive services, adjunctive dental, orthodontic, or prosthodontic support, and treatment for secondary conditions, while explicitly excluding purely cosmetic surgery. Cost-sharing requirements for these services cannot be more restrictive than those for other medical and surgical benefits.
Proponents argue
Proponents argue that this bill addresses a critical gap in health insurance coverage, ensuring that individuals, especially children, with congenital anomalies or birth defects affecting the face and mouth receive the medically necessary care they need to achieve normal function and appearance. They emphasize that these conditions are not cosmetic but impact basic life functions like eating, speaking, and breathing, and that current coverage often forces families into significant financial hardship.
Opponents contend
Potential opponents might argue that mandating specific coverage requirements could increase healthcare premiums for all policyholders, placing an additional burden on employers and individuals. They might also raise concerns about the scope of 'medically necessary' determinations and the potential for disputes over what constitutes 'normal appearance' versus purely cosmetic enhancements, despite the bill's explicit exclusion.
The bill is concise and clearly written, making it accessible for an informed reader to understand its core provisions within a reasonable timeframe.
Section 2(a) (Public Health Service Act), 2(b) (ERISA), 2(c) (Internal Revenue Code)
Mandated Coverage for Congenital Anomaly or Birth Defect Treatment
This core provision requires group health plans and health insurance issuers to cover outpatient and inpatient services for diagnosing and treating congenital anomalies or birth defects that primarily affect the eyes, ears, teeth, mouth, or jaw. It ensures that financial requirements like deductibles and copayments are no more restrictive than those applied to substantially all other medical and surgical benefits covered by the plan or coverage.
Supporters argue
Supporters argue this provision is crucial for ensuring equitable access to care for a vulnerable population, preventing financial ruin for families, and allowing individuals to achieve normal function and appearance, which significantly impacts quality of life.
Critics contend
Critics might contend that this mandate could lead to increased premiums for all policyholders, as insurers pass on the costs of expanded coverage. They may also argue it interferes with market-based health plan design.
Tradeoffs
This provision balances the need for comprehensive care for specific conditions against potential increases in healthcare costs and premiums for the broader insured population.
Section 2(a)(3), 2(b)(3), 2(c)(3)
Detailed Definition of Covered Treatments and Exclusions
This section specifies that covered services include those to improve, repair, or restore body parts to achieve normal functioning or appearance, as determined medically necessary by the treating physician. It explicitly includes reconstructive services, adjunctive dental, orthodontic, or prosthodontic support from birth until treatment completion, and services for secondary conditions. Crucially, it also clearly excludes cosmetic surgery performed solely to reshape normal structures for appearance or self-esteem, if not medically determined as a result of a congenital anomaly.
Section 2(a)(b), 2(b)(b), 2(c)(b)
Requirement for Health Plans to Provide Notice of Coverage
Beginning January 1, 2026, group health plans and health insurance issuers must provide notice to each participant and beneficiary regarding the coverage required by this section. This notice must be included in any documents describing services, in accordance with regulations promulgated by the Secretary.
Section 2(d)
HHS Study on Network Adequacy and Out-of-Pocket Costs
The Secretary of Health and Human Services is required to conduct a study and submit a report to Congress by December 31, 2027. This study will evaluate the sufficiency and accessibility of provider networks for treating congenital anomalies and assess any changes in patient out-of-pocket costs and overall procedure costs resulting from the new coverage requirements.
The bill mandates coverage for adjunctive dental, orthodontic, or prosthodontic support related to congenital anomalies, explicitly stating this coverage applies 'notwithstanding any exclusions, limitations, or restrictions under the plan or health insurance coverage on coverage of dental, orthodontic, or prosthodontic items and services arising from other injuries or sicknesses.'
Section 2(a)(3)(A)(ii)(II), 2(b)(3)(A)(ii)(II), 2(c)(3)(A)(ii)(II)
Why it matters:This is a common legislative technique to ensure a specific provision takes precedence over general rules, rather than an attempt to hide it. However, its technical phrasing can obscure its significant impact.
Case for: Proponents argue this language is essential to prevent insurers from using existing dental exclusions to deny coverage for medically necessary oral and facial reconstruction related to birth defects, which are often inseparable from overall health and function, such as eating and speaking.
Case against: Opponents might argue that this specific override could create a precedent for other conditions to seek similar exemptions from standard plan exclusions, potentially complicating health plan administration and increasing costs beyond initial estimates.
Estimated impact: Ensures comprehensive oral and facial care for affected individuals, potentially shifting significant costs for long-term treatments from families to insurance plans.