Ensuring Lasting Smiles Act

The "Ensuring Lasting Smiles Act" mandates that group health plans and health insurance issuers provide comprehensive coverage for the diagnosis and treatment of congenital anomalies or birth defects. This requirement specifically targets conditions that primarily impact the appearance or function of the eyes, ears, teeth, mouth, or jaw, aiming to ensure individuals receive necessary care for these conditions. Covered services include any medically necessary items or services designed to improve, repair, or restore normal body functioning or appearance, or to approximate a normal appearance. This explicitly encompasses reconstructive services and procedures , along with adjunctive dental, orthodontic, or prosthodontic support from birth until the completion of medical or surgical treatment, including ongoing maintenance. However, the bill clarifies that cosmetic surgery performed solely to reshape normal structures for appearance or self-esteem, not medically determined as a result of a congenital anomaly, is not covered. Health plans may impose cost-sharing requirements, such as coinsurance, copayments, and deductibles, but these financial obligations must be no more restrictive than those applied to substantially all other medical and surgical benefits. Plans and issuers are also required to provide notice of this mandated coverage to participants and beneficiaries by January 1, 2026. The new coverage requirements will become effective for plan years beginning on or after January 1, 2026. Furthermore, the bill directs the Secretary of Health and Human Services to conduct a study and submit a report to Congress by December 31, 2027. This report will evaluate the sufficiency and accessibility of provider networks for these specialized services and assess any changes in patient out-of-pocket costs and overall procedure costs resulting from the new coverage mandates.