,,ii  #aagth ,,congress  #ast ,session  
,s4 #ged  ,,in ,,the ,,senate ,,of ,,the
 ,,united ,,states  ,march #af1         
#bjba,ms4 ,baldwin 7for herself1 ,ms4   
,ernst1 ,mr4 ,brown1 ,ms4 ,murkowski1   
,ms4 ,klobuchar1 ,mr4 ,marshall1 ,mrs4  
,shaheen1 ,mr4 ,wicker1 ,mr4            
,whitehouse1 ,mr4 ,tillis1 ,ms4         
,stabenow1 ,mr4 ,cramer1 ,mr4 ,van      
,hollen1 ,mr4 ,boozman1 ,mr4 ,peters1   
,ms4 ,collins1 ,mr4 ,markey1 ,mrs4      
,capito1 ,mr4 ,booker1 ,mr4 ,graham1    
,ms4 ,smith1 ,mr4 ,grassley1 ,ms4       
,sinema1 ,mr4 ,moran1 ,mr4 ,murphy1 ,mr4
 ,daines1 ,mr4 ,blumenthal1 ,mr4 ,braun1
 and ,mr4 ,reed7 introduced the         
following bill2 which was read twice and
 referred to the ,committee on ,health1 
,education1 ,labor1 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 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 ,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 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    
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 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 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
 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 ,a group      
health plan under this part shall comply
 with the notice requirement under      
section #gad7;c7 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  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     
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 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 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 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 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 
,a group health plan under this part    
shall comply with the notice requirement
 under section #gad7;c7 with respect to 
the requirements of this section as if  
such section applied to such plan4  4   
7#b7 ,technical amendments  7,a7        
,section #gcb7;a7 of such ,act 7#bi     
,u4,s4,c4 #aaia;a7a77 is amended by     
striking section #gaa and inserting     
sections #gaa and #gbf4  7,b7 ,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 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 #aihf
 is amended by adding at the end the    
following3  #ihbf4 ,standards relating  
to benefits for 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        
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 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 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 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 
,a group health plan under this part    
shall comply with the notice requirement
 under section #gad7;c7 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 ,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 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 ,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 #bgii;,a-#aa   
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 
7f7 ,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
 #bjbb1 and with respect to health      
insurance coverage offered1 sold1       
issued1 renewed1 in effect1 or operated 
in the individual market on or after    
such date4  7g7 ,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 ,a1 ,c1 and ,d of   
title ,,xxvii of the ,public ,health    

,service ,act1 and chapter #ajj of the  
,internal ,revenue ,code of #aihf4