H.R. 3277: Ensuring Lasting Smiles Act

The Ensuring Lasting Smiles Act would require most private health plans to cover care for congenital anomalies or birth defects that mainly affect the appearance or function of the eyes, ears, teeth, mouth, or jaw. That matters because patients with conditions like cleft lip and cleft palate often need years of treatment, but insurers may now classify some of that care as dental, orthodontic, or cosmetic and deny coverage.

The bill tries to close those loopholes. It says plans must cover inpatient and outpatient services tied to diagnosis and treatment, including reconstructive procedures, treatment of complications, diagnostic services, and ongoing dental, orthodontic, or prosthodontic support when a treating physician says the care is medically necessary. It also says insurers cannot impose tougher cost-sharing rules on this care than they use for most other medical and surgical benefits.

A key part of the bill is its broad view of treatment. Coverage would not stop at one surgery. It would extend from birth until treatment is completed, including later care needed to maintain function or approximate a normal appearance. It also includes care for secondary conditions and follow-up treatment related to the underlying defect. That is especially important for conditions that require staged treatment over many years.

The bill does draw a line: it does not require plans to cover cosmetic surgery done only to improve appearance or self-esteem when there is no medical determination that the patient has a congenital anomaly or birth defect. In practice, the biggest policy fight is likely to be over where insurers, doctors, and regulators draw the line between medically necessary reconstructive care and excluded cosmetic care, and how much premiums could rise if plans must cover more services.