,,ii #aaith ,,congress #ast ,session ,s4 #afgg ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,may #h1 #bjbe ,ms4 ,baldwin 7for herself1 ,ms4 ,ernst1 ,ms4 ,klobuchar1 ,ms4 ,murkowski1 ,mr4 ,lujn1 ,mr4 ,tillis1 ,mr4 ,king1 ,mr4 ,marshall1 ,mr4 ,reed1 ,mr4 ,grassley1 ,mr4 ,blumenthal1 ,mr4 ,booker1 and ,mr4 ,merkley7 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 ,coverage of 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 defect that primarily impacts the appearance or function of the eyes1 ears1 teeth1 mouth1 or jaw1 consistent with paragraphs 7#b7 and 7#c74 7#b7 ,financial requirements ,any coverage provided under paragraph 7#a7 under a group health plan or group or individual health insurance coverage may be subject to cost-sharing requirements 7such as coinsurance1 copayments1 and deductibles71 as required by the plan or issuer offering such coverage1 that are no more restrictive than the predominant cost-sharing requirements applied to substantially all other medical and surgical benefits covered by the plan or coverage4 7#c7 ,applicable items and services 7,a7 ,in general ,except as provided in subparagraph 7,b71 the items and services required under paragraph 7#a7 to be covered by a group health plan or group or individual health insurance coverage offered by a health insurance issuer include-- 7i7 any item or service to improve1 repair1 or restore any body part to achieve normal body functioning or appearance1 or performed to approximate a normal appearance1 as determined medically necessary by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 on account of a congenital anomaly or birth defect that primarily impacts the appearance or function of the eyes1 ears1 teeth1 mouth1 or jaw2 and 7ii7 any treatment or diagnostic service with respect to any and all missing or abnormal body parts 7including teeth1 the oral cavity1 and their associated structures71 as determined medically necessary by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 including-- 7,i7 reconstructive services and procedures1 and items and services related to any complications arising from such services and procedures2 7,,ii7 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 appearance1 notwithstanding any exclusions1 limitations1 or restrictions under the plan or health insurance coverage on coverage of dental1 orthodontic1 or prosthodontic items and services arising from other injuries or sicknesses2 and 7,,iii7 items and services related to secondary conditions and follow-up treatment associated with the underlying congenital anomaly or birth defect4 7,b7 ,exception ,the items and services required under this subsection to be covered by a group health plan or health insurance issuer offering group or individual health insurance coverage shall not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem1 if such items and services are not furnished as a result of a medical determination of a congenital anomaly or birth defect4 7b7 ,notice ,beginning not later ,january #a1 #bjbf1 a group health plan or health insurance issuer offering group or individual health insurance coverage shall provide notice to each participant and beneficiary under such plan or coverage regarding the coverage required by this section in any documents describing services1 in accordance with any regulations promulgated by the ,secretary4 7c7 ,definition ,in this section1 the term congenital anomaly or birth defect means a structural or functional anomaly that occurs during intrauterine life1 develops prenatally1 and may be identified before birth1 at birth1 or later in life1 and which may-- 7#a7 be caused by genetic or chromosomal disorders1 embryotoxic or teratogenic environmental factors1 nutrient deficiency1 multifactorial inheritance1 or be of an unknown cause2 7#b7 manifest as abnormal anatomical structures2 7#c7 manifest as physical1 sensory1 or cognitive functional disabilities2 7#d7 manifest as syndromes1 diseases1 or other health problems2 and 7#e7 manifest as singular anomalies or in combination prenatally1 at birth1 or later in life4 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 ,coverage of 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 defect that primarily impacts the appearance or function of the eyes1 ears1 teeth1 mouth1 or jaw1 consistent with paragraphs 7#b7 and 7#c74 7#b7 ,financial 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 cost-sharing requirements 7such as coinsurance1 copayments1 and deductibles71 as required by the plan or issuer offering such coverage1 that are no more restrictive than the predominant cost-sharing requirements applied to substantially all other medical and surgical benefits covered by the plan or coverage4 7#c7 ,applicable items and services 7,a7 ,in general ,except as provided in subparagraph 7,b71 the items and services required under paragraph 7#a7 to be covered by a group health plan or group health insurance coverage offered by a health insurance issuer include-- 7i7 any item or service to improve1 repair1 or restore any body part to achieve normal body functioning or appearance1 or performed to approximate a normal appearance1 as determined medically necessary by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 on account of a congenital anomaly or birth defect that primarily impacts the appearance or function of the eyes1 ears1 teeth1 mouth1 or jaw2 and 7ii7 any treatment or diagnostic service with respect to any and all missing or abnormal body parts 7including teeth1 the oral cavity1 and their associated structures71 as determined medically necessary by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 including-- 7,i7 reconstructive services and procedures1 and items and services related to any complications arising from such services and procedures2 7,,ii7 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 appearance1 notwithstanding any exclusions1 limitations1 or restrictions under the plan or health insurance coverage on coverage of dental1 orthodontic1 or prosthodontic items and services arising from other injuries or sicknesses2 and 7,,iii7 items and services related to secondary conditions and follow-up treatment associated with the underlying congenital anomaly or birth defect4 7,b7 ,exception ,the items and services required under this subsection to be covered by a group health plan or health insurance issuer offering group health insurance coverage shall not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem1 if such items and services are not furnished as a result of a medical determination of a congenital anomaly or birth defect4 7b7 ,notice ,beginning not later than ,january #a1 #bjbf1 a group health plan or health insurance issuer offering group health insurance coverage shall provide notice to each participant and beneficiary under such plan or coverage regarding the coverage required by this section1 in any documents describing services1 in accordance with any regulations promulgated by the ,secretary4 7c7 ,definition ,in this section1 the term congenital anomaly or birth defect means a structural or functional anomaly that occurs during intrauterine life1 develops prenatally1 and may be identified before birth1 at birth1 or later in life1 and which may-- 7#a7 be caused by genetic or chromosomal disorders1 embryotoxic or teratogenic environmental factors1 nutrient deficiency1 multifactorial inheritance1 or be of an unknown cause2 7#b7 manifest as abnormal anatomical structures2 7#c7 manifest as physical1 sensory1 or cognitive functional disabilities2 7#d7 manifest as syndromes1 diseases1 or other health problems2 and 7#e7 manifest as singular anomalies or in combination prenatally1 at birth1 or later in life4 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 ,coverage of 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 ,coverage of 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 defect that primarily impacts the appearance or function of the eyes1 ears1 teeth1 mouth1 or jaw1 consistent with paragraphs 7#b7 and 7#c74 7#b7 ,financial requirements ,any coverage provided under paragraph 7#a7 under a group health plan may be subject to cost-sharing requirements 7such as coinsurance1 copayments1 and deductibles71 as required by the plan1 that are no more restrictive than the predominant cost-sharing requirements applied to substantially all other medical and surgical benefits covered by the plan4 7#c7 ,applicable items and services 7,a7 ,in general ,except as provided in subparagraph 7,b71 the items and services required under paragraph 7#a7 to be covered by a group health plan include-- 7i7 any item or service to improve1 repair1 or restore any body part to achieve normal body functioning or appearance1 or performed to approximate a normal appearance1 as determined medically necessary by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 on account of a congenital anomaly or birth defect that primarily impacts the appearance or function of the eyes1 ears1 teeth1 mouth1 or jaw2 and 7ii7 any treatment or diagnostic service with respect to any and all missing or abnormal body parts 7including teeth1 the oral cavity1 and their associated structures71 as determined medically necessary by the treating physician 7as defined in section #ahfa7r7 of the ,social ,security ,act71 including-- 7,i7 reconstructive services and procedures1 and items and services related to any complications arising from such services and procedures2 7,,ii7 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 appearance1 notwithstanding any exclusions1 limitations1 or restrictions under the plan on coverage of dental1 orthodontic1 or prosthodontic items and services arising from other injuries or sicknesses2 and 7,,iii7 items and services related to secondary conditions and follow-up treatment associated with the underlying congenital anomaly or birth defect4 7,b7 ,exception ,the items and services required under this subsection to be covered by a group health plan shall not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem1 if such items and services are not furnished as a result of a medical determination of a congenital anomaly or birth defect4 7b7 ,notice ,beginning not later ,january #a1 #bjbf1 a group health plan shall provide notice to each participant and beneficiary under such plan or coverage regarding the coverage required by this section in any documents describing services1 in accordance with any regulations promulgated by the ,secretary4 7c7 ,definition ,in this section1 the term congenital anomaly or birth defect means a structural or functional anomaly that occurs during intrauterine life1 develops prenatally1 and may be identified before birth1 at birth1 or later in life1 and which may-- 7#a7 be caused by genetic or chromosomal disorders1 embryotoxic or teratogenic environmental factors1 nutrient deficiency1 multifactorial inheritance1 or be of an unknown cause2 7#b7 manifest as abnormal anatomical structures2 7#c7 manifest as physical1 sensory1 or cognitive functional disabilities2 7#d7 manifest as syndromes1 diseases1 or other health problems2 and 7#e7 manifest as singular anomalies or in combination prenatally1 at birth1 or later in life4 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 ,coverage of congenital anomaly or birth defect4 4 7d7 ,study and report on network adequacy ,the ,secretary of ,health and ,human ,services shall conduct a study1 and not later than ,december #ca1 #bjbg1 submit a report to ,congress1 on the matters relating to access of services for coverage of outpatient and inpatient items and services related to the diagnosis and treatment of a congenital anomaly or birth defect that primarily impacts the appearance or function of the eyes1 ears1 teeth1 mouth1 or jaw4 ,such study and report shall-- 7#a7 evaluate the sufficiency and accessibility of networks of providers that perform services related to the diagnosis and treatment of such congenital anomalies and birth defects under group health plans and group and individual health insurance coverage 7as such terms are defined in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia772 and 7#b7 assess any change in out-of-pocket costs for patients1 by procedure type1 resulting from the coverage requirements under sections #bgii;,a-#aa of the ,public ,health ,service ,act1 #gbf of the ,employee ,retirement ,income ,security ,act of #aigd1 and #ihbf of the ,internal ,revenue ,code of #aihf1 as added by this section1 and any change in the overall procedure cost for such services4 7e7 ,effective date ,the amendments made by subsections 7a71 7b71 and 7c7 shall apply with respect to plan years beginning on or after ,january #a1 #bjbf4