,i #aagth ,,congress #b;d ,session ,h4 ,r4 #ggjb ,,in ,,the ,,house ,,of ,,representatives ,may #aj1 #bjbb,mr4 ,dunn 7for himself and ,mr4 ,griffith7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,education and ,labor1 and ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 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 craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 #a4 ,short title ,this ,act may be cited as the ,ensuring ,lasting ,smiles ,act4 #b4 ,coverage of craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect 7a7 ,public ,health ,service ,act ,amendments ,part ,d of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq47 is amended by adding at the end the following new section3 #bgii;,a-#aa4 ,standards relating to benefits for craniofacial1 oral1 or maxillofacial 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 items and services related to the diagnosis and treatment of a craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 7#b7 ,requirements 7,a7 ,in general ,coverage provided under paragraph 7#a7 shall include any medically necessary item or service to functionally improve1 repair1 or restore any body part to achieve normal body functioning or appearance1 as determined by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 due to craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 7,b7 ,financial requirements and treatment requirements ,any coverage provided under paragraph 7#a7 under a group health plan or individual or group health insurance coverage offered by a health insurance issuer may be subject to coverage limits 7such as medical necessity1 pre-authorization1 or pre-certification7 and cost-sharing requirements 7such as coinsurance1 copayments1 and deductibles71 as required by the plan or issuer1 that are no more restrictive than the predominant coverage limits and cost-sharing requirements1 respectively1 applied to substantially all medical and surgical benefits covered by the plan 7or coverage74 7#c7 ,treatment defined ,in this section3 7,a7 ,in general ,except as provided in subparagraph 7,b71 the term treatment includes1 with respect to a group health plan or group or individual health insurance coverage offered by a health insurance issuer1 inpatient and outpatient items and services performed to improve1 repair1 or restore bodily function 7or performed to approximate a normal appearance71 due to a craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect1 and includes treatment to any and all missing or abnormal body parts 7including teeth1 the oral cavity1 and their associated structures7 that would otherwise be provided under the plan or coverage for any other injury or sickness1 including-- 7i7 any items or services1 including inpatient and outpatient care1 reconstructive services and procedures1 and complications thereof2 7ii7 adjunctive dental1 orthodontic1 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 materially improve1 repair1 or restore bodily function2 and 7iv7 procedures for secondary conditions and follow-up treatment associated with the underlying craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 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 ,not later than one year after the date of the enactment of this section and annually thereafter1 a group health plan1 and a health insurance issuer offering group or individual health insurance coverage1 shall1 in accordance with regulations or guidance issued by the ,secretary1 provide to each enrollee under such plan or coverage a written description of the terms of this section4 ,such description shall be in language which is understandable to the typical enrollee4 4 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 #gbf4 ,standards relating to benefits for craniofacial1 oral1 or maxillofacial 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 health insurance coverage1 shall provide coverage for outpatient and inpatient items and services related to the diagnosis and treatment of a craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 7#b7 ,requirements 7,a7 ,in general ,coverage provided under paragraph 7#a7 shall include any medically necessary item or service to functionally improve1 repair1 or restore any body part to achieve normal body functioning or appearance1 as determined by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 due to craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 7,b7 ,financial requirements and treatment requirements ,any coverage provided under paragraph 7#a7 under a group health plan or group health insurance coverage offered by a health insurance issuer may be subject to coverage limits 7such as medical necessity1 pre-authorization1 or pre-certification7 and cost-sharing requirements 7such as coinsurance1 copayments1 and deductibles71 as required by the plan or issuer1 that are no more restrictive than the predominant coverage limits and cost-sharing requirements1 respectively1 applied to substantially all medical and surgical benefits covered by the plan 7or coverage74 7#c7 ,treatment defined ,in this section3 7,a7 ,in general ,except as provided in subparagraph 7,b71 the term treatment includes1 with respect to a group health plan or group health insurance coverage offered by a health insurance issuer1 inpatient and outpatient items and services performed to improve1 repair1 or restore bodily function 7or performed to approximate a normal appearance71 due to a craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect1 and includes treatment to any and all missing or abnormal body parts 7including teeth1 the oral cavity1 and their associated structures7 that would otherwise be provided under the plan or coverage for any other injury or sickness1 including-- 7i7 any items or services1 including inpatient and outpatient care1 reconstructive services and procedures1 and complications thereof2 7ii7 adjunctive dental1 orthodontic1 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 materially improve1 repair1 or restore bodily function2 and 7iv7 procedures for secondary conditions and follow-up treatment associated with the underlying craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 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 ,not later than one year after the date of the enactment of this section and annually thereafter1 a group health plan1 and a health insurance issuer offering group health insurance coverage1 shall1 in accordance with regulations or guidance issued by the ,secretary1 provide to each participant or beneficiary under such plan or coverage a written description of the terms of this section4 ,such description shall be in language which is understandable to the typical participant or beneficiary4 4 7#b7 ,technical amendment ,the table of contents in section #a of such ,act is amended by inserting after the item relating to section #gbe the following new item3 ,sec4 #gbf4 ,standards relating to benefits for craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 4 7c7 ,internal ,revenue ,code amendments 7#a7 ,in general ,subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following3 #ihbf4 ,standards relating to benefits for craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect 7a7 ,requirements for care and ,reconstructive ,treatment 7#a7 ,in general ,a group health plan shall provide coverage for outpatient and inpatient items and services related to the diagnosis and treatment of a craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 7#b7 ,requirements 7,a7 ,in general ,coverage provided under paragraph 7#a7 shall include any medically necessary item or service to functionally improve1 repair1 or restore any body part to achieve normal body functioning or appearance1 as determined by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 due to craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 7,b7 ,financial requirements and treatment requirements ,any coverage provided under paragraph 7#a7 under a group health plan may be subject to coverage limits 7such as medical necessity1 pre-authorization1 or pre-certification7 and cost-sharing requirements 7such as coinsurance1 copayments1 and deductibles71 as required by the plan1 that are no more restrictive than the predominant coverage limits and cost-sharing requirements1 respectively1 applied to substantially all medical and surgical benefits covered by the plan4 7#c7 ,treatment defined ,in this section3 7,a7 ,in general ,except as provided in subparagraph 7,b71 the term treatment includes1 with respect to a group health plan1 inpatient and outpatient items and services performed to improve1 repair1 or restore bodily function 7or performed to approximate a normal appearance71 due to a craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect1 and includes treatment to any and all missing or abnormal body parts 7including teeth1 the oral cavity1 and their associated structures7 that would otherwise be provided under the plan for any other injury or sickness1 including-- 7i7 any items or services1 including inpatient and outpatient care1 reconstructive services and procedures1 and complications thereof2 7ii7 adjunctive dental1 orthodontic1 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 materially improve1 repair1 or restore bodily function2 and 7iv7 procedures for secondary conditions and follow-up treatment associated with the underlying craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 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 ,not later than one year after the date of the enactment of this section and annually thereafter1 a group health plan shall1 in accordance with regulations or guidance issued by the ,secretary1 provide to each enrollee under such plan a written description of the terms of this section4 ,such description shall be in language which is understandable to the typical enrollee4 4 7#b7 ,clerical amendment ,the table of sections for such subchapter is amended by adding at the end the following new item3 ,sec4 #ihbf4 ,standards relating to benefits for craniofacial1 oral1 or maxillofacial congenital anomaly or birth defect4 4 7d7 ,rule of construction ,a group health plan or health insurance issuer shall provide the benefits described in section #bgii;,a-#aa of the ,public ,health ,service ,act 7as added by subsection 7a771 section #gbf of the ,employee ,retirement ,income ,security ,act of #aigd 7as added by subsection 7b771 and section #ihbf of the ,internal ,revenue ,code of #aihf 7as added by subsection 7c77 under the terms of such plan or health insurance coverage offered by such issuer4 7e7 ,effective date ,the amendments made by this section shall apply with respect to plan years beginning on or after ,january #a1 #bjbd4