,,ii  #aafth ,,congress  #ast ,session  
,s4 #efj  ,,in ,,the ,,senate ,,of ,,the
 ,,united ,,states  ,february #bf1      
#bjai,ms4 ,baldwin 7for herself1 ,ms4   
,ernst1 ,ms4 ,murkowski1 and ,mr4       
,brown7 introduced the following bill2  
which was read twice and referred to the
 ,committee on ,health1 ,education1     
,labor1 and ,pensions  ,a ,,bill  ,to   
amend the ,public ,health ,service ,act1
 the ,employee ,retirement ,income      
,security ,act of #aigd1 and the        
,internal ,revenue ,code of #aihf to    
require that group and individual health
 insurance coverage and group health    
plans provide coverage for treatment of 
a congenital anomaly or birth defect4   
#a4 ,short title ,this ,act may be cited
 as the ,ensuring ,lasting ,smiles ,act4
  #b4 ,coverage of congenital anomaly or
 birth defect  7a7 ,public ,health      
,service ,act ,amendments  7#a7 ,in     
general ,title ,,xxvii of the ,public   
,health ,service ,act is amended by     
inserting after section #bgbi 7#db      

,u4,s4,c4 #cjj;gg-#ai;b71 the following3
  #bgcj4 ,standards relating to benefits
 for congenital anomaly or birth defect 
7a7 ,requirements for care and          
,reconstructive ,treatment  7#a7 ,in    
general ,a group health plan1 and a     
health insurance issuer offering group  
or individual health insurance coverage1
 shall provide coverage for outpatient  
and inpatient services related to the   
diagnosis and treatment of a congenital 
anomaly or birth defect4  7#b7          
,requirements ,coverage provided under  
paragraph 7#a7 shall include any service
 to functionally improve1 repair1 or    
restore any body part that is medically 
necessary to achieve normal body        
functioning or appearance1 as determined
 by the treating physician 7as defined  
in section #ahfa of the ,social         
,security ,act74 ,any coverage provided 
under such paragraph may be subject to  
coverage limits1 such as                
pre-authorization or pre-certification1 
as required by the plan or issuer that  

are no more restrictive than the        
predominant treatment limitations       
applied to substantially all medical and
 surgical benefits covered by the plan  
7or coverage74  7#c7 ,treatment defined 
7,a7 ,in general ,except as provided in 
subparagraph 7,b71 in this section1 the 
term treatment includes patient and     
outpatient care and services performed  
to improve or restore body function 7or 
performed to approximate a normal       
appearance71 due to congenital anomaly  
or birth defect and shall include       
treatment to any and all missing or     
abnormal body parts1 7including teeth1  
the oral cavity1 and their associated   
structures7 that would otherwise be     
provided under the plan or coverage for 
any other injury and sickness1          
including--  7i7 inpatient and          
outpatient care1 reconstructive services
 and procedures1 and complications      
thereof1 including prosthetics and      
appliances2  7ii7 adjunctive dental1    
orthodontic or prosthodontic support    

from birth until the medical or surgical
 treatment of the defect or anomaly has 
been completed1 including ongoing or    
subsequent treatment required to        
maintain function or approximate a      
normal appearance2  7iii7 procedures    
that do not materially restore or       
improve the function of the body part   
being treated2 and  7iv7 procedures for 
secondary conditions and follow-up      
treatment4  7,b7 ,exception ,the term   
treatment shall not include cosmetic    
surgery performed to reshape normal     
structures of the body to improve       
appearance or self-esteem4  7b7 ,notice 
,a group health plan under this part    
shall comply with the notice requirement
 under section #gad7;b7 of the ,employee
 ,retirement ,income ,security ,act of  
#aigd with respect to the requirements  
of this section as if such section      
applied to such plan4  4  7#b7          
,technical amendments  7,a7 ,section    
#bgbd7;c7 of the ,public ,health        
,service ,act 7#db ,u4,s4,c4            

#cjj;gg-#bc7;c77 is amended by striking 
section #bgjd and inserting sections    
#bgbe and #bgcj4  7,b7 ,section         
#bgfb7;b77#b7 of the ,public ,health    
,service ,act 7#db ,u4,s4,c4            
#cjj;gg-#fb7;b77#b77 is amended by      
striking section #bgea and inserting    
sections #bgcj and #bgea4  7b7 ,,erisa  
amendments  7#a7 ,in general ,subpart ,b
 of part #g of subtitle ,b of title ,i  
of the ,employee ,retirement ,income    
,security ,act of #aigd is amended by   
adding at the end the following3  #gaf4 
,standards relating to benefits for     
congenital anomaly or birth defect  7a7 
,requirements for ,reconstructive       
,treatment  7#a7 ,in general ,a group   
health plan1 and a health insurance     
issuer offering group or individual     
health insurance coverage1 shall provide
 coverage for outpatient and inpatient  
services related to the diagnosis and   
treatment of a congenital anomaly or    
birth defect4  7#b7 ,requirements       
,coverage provided under paragraph 7#a7 

shall include any service to            
functionally improve1 repair1 or restore
 any body part that is medically        
necessary to achieve normal body        
functioning or appearance1 as determined
 by the treating physician 7as defined  
in section #ahfa of the ,social         
,security ,act74 ,any coverage provided 
under such paragraph may be subject to  
coverage limits1 such as                
pre-authorization or pre-certification1 
as required by the plan or issuer that  
are no more restrictive than the        
predominant treatment limitations       
applied to substantially all medical and
 surgical benefits covered by the plan  
7or coverage74  7#c7 ,treatment defined 
7,a7 ,in general ,except as provided in 
subparagraph 7,b71 in this section1 the 
term treatment includes patient and     
outpatient care and services performed  
to improve or restore body function 7or 
performed to approximate a normal       
appearance71 due to congenital anomaly  
or birth defect and shall include       

treatment to any and all missing or     
abnormal body parts1 7including teeth1  
the oral cavity1 and their associated   
structures7 that would otherwise be     
provided under the plan or coverage for 
any other injury and sickness1          
including--  7i7 inpatient and          
outpatient care1 reconstructive services
 and procedures1 and complications      
thereof1 including prosthetics and      
appliances2  7ii7 adjunctive dental1    
orthodontic or prosthodontic support    
from birth until the medical or surgical
 treatment of the defect or anomaly has 
been completed1 including ongoing or    
subsequent treatment required to        
maintain function or approximate a      
normal appearance2  7iii7 procedures    
that do not materially restore or       
improve the function of the body part   
being treated2 and  7iv7 procedures for 
secondary conditions and follow-up      
treatment4  7,b7 ,exception ,the term   
treatment shall not include cosmetic    
surgery performed to reshape normal     

structures of the body to improve       
appearance or self-esteem4  7b7 ,notice 
under group health plan ,the imposition 
of the requirements of this section     
shall be treated as a material          
modification in the terms of the plan   
described in the last sentence of       
section #ajb7;a71 for purposes of       
assuring notice of such requirements    
under the plan1 except that the summary 
description required to be provided     
under the fourth sentence of section    
#ajd7;b77#a7 with respect to such       
modification shall be provided by not   
later than #fj days after the first day 
of the first plan year in which such    
requirements apply4  4  7#b7 ,technical 
amendments  7,a7 ,section #gca7;c7 of   
such ,act 7#bi ,u4,s4,c4 #aaia7;c77 is  
amended by striking section #gaa and    
inserting sections #gaa and #gaf4  7,b7 
,section #gcb7;a7 of such ,act 7#bi     
,u4,s4,c4 #aaia;a7a77 is amended by     
striking section #gaa and inserting     
sections #gaa and #gaf4  7,c7 ,the table

 of contents in section #a of such ,act 
is amended by inserting after the item  
relating to section #gad the following  
new items3 ,sec4 #gae4 ,additional      
market reforms4,sec4 #gaf4 ,standards   
relating to benefits for congenital     
anomaly or birth defect4  7c7 ,internal 
,revenue ,code amendments  7#a7 ,in     
general ,subchapter ,b of chapter #ajj  
of the ,internal ,revenue ,code of      
#aihf1 as amended by subsection 7f7 of  
the section #aefc 7relating to          
conforming amendments7 of ,public ,law  
#aaa-adh1 is amended by adding at the   
end the following3  #ihaf4 ,standards   
relating to benefits for congenital     
anomaly or birth defect  7a7            
,requirements for ,reconstructive       
,treatment ,a group health plan1 and a  
health insurance issuer offering group  
or individual health insurance coverage1
 shall provide coverage for outpatient  
and inpatient services related to the   
diagnosis and treatment of a congenital 
anomaly or birth defect4  7b7           

,requirements ,coverage provided under  
subsection 7a7 shall include any service
 to functionally improve1 repair1 or    
restore any body part that is medically 
necessary to achieve normal body        
functioning or appearance1 as determined
 by the treating physician 7as defined  
in section #ahfa of the ,social         
,security ,act74 ,any coverage provided 
under such subsection may be subject to 
coverage limits1 such as                
pre-authorization or pre-certification1 
as required by the plan or issuer that  
are no more restrictive than the        
predominant treatment limitations       
applied to substantially all medical and
 surgical benefits covered by the plan  
7or coverage74  7c7 ,treatment defined  
7#a7 ,in general ,except as provided in 
paragraph 7#b71 in this section1 the    
term treatment includes patient and     
outpatient care and services performed  
to improve or restore body function 7or 
performed to approximate a normal       
appearance71 due to congenital anomaly  

or birth defect and shall include       
treatment to any and all missing or     
abnormal body parts1 7including teeth1  
the oral cavity1 and their associated   
structures7 that would otherwise be     
provided under the plan or coverage for 
any other injury and sickness1          
including--  7,a7 inpatient and         
outpatient care1 reconstructive services
 and procedures1 and complications      
thereof1 including prosthetics and      
appliances2  7,b7 adjunctive dental1    
orthodontic or prosthodontic support    
from birth until the medical or surgical
 treatment of the defect or anomaly has 
been completed1 including ongoing or    
subsequent treatment required to        
maintain function or approximate a      
normal appearance2  7,c7 procedures that
 do not materially restore or improve   
the function of the body part being     
treated2 and  7,d7 procedures for       
secondary conditions and follow-up      
treatment4  7#b7 ,exception ,the term   
treatment shall not include cosmetic    

surgery performed to reshape normal     
structures of the body to improve       
appearance or self-esteem4  4  7#b7     
,clerical amendment ,the table of       
sections for such subchapter is amended 
by adding at the end the following new  
items3  ,sec4 #ihae4 ,additional market 
reforms4,sec4 #ihaf4 ,standards relating
 to benefits for congenital anomaly or  
birth defect4  4  7d7 ,clarifying       
amendment regarding application to      
grandfathered plans ,section            
#abea7;a77#d77;,a7 of the ,patient      
,protection and ,affordable ,care ,act  
7#db ,u4,s4,c4 #ahjaa7;a77#d77;,a771 is 
amended by adding at the end the        
following3  7v7 ,section #bgcj 7relating
 to standards relating to benefits for  
congenital anomaly or birth defect71 as 
added by section #b7;a7 of the ,ensuring
 ,lasting ,smiles ,act4  4  7e7         
,effective date ,the amendments made by 
this section shall apply with respect to
 group health plans for plan years      
beginning on or after ,january #a1      

#bjbj1 and with respect to health       
insurance coverage offered1 sold1       
issued1 renewed1 in effect1 or operated 
in the individual market on or after    
such date4  7f7 ,coordinated regulations
 ,section #ajd7a7 of the ,health        
,insurance ,portability and             
,accountability ,act of #aiif is amended
 by striking this subtitle 7and the     
amendments made by this subtitle and    
section #dja7 and inserting the         
provisions of part #g of subtitle ,b of 
title ,i of the ,employee ,retirement   
,income ,security ,act of #aigd1 the    
provisions of parts ,a and ,c of title  
,,xxvii of the ,public ,health ,service 
,act1 and chapter #ajj of the ,internal 
,revenue ,code of #aihf4