H.R. 3277: Ensuring Lasting Smiles Act

Treating a cleft lip or cleft palate isn't one surgery. Over years — sometimes two decades — a child may need reconstructive surgery, orthodontics, dental work, prosthetics, hearing care, and follow-up procedures. Insurers routinely split that care into buckets and deny large chunks of it as 'dental,' 'orthodontic,' or 'cosmetic.'

H.R. 3277 — the Ensuring Lasting Smiles Act — tells most private health plans they can't do that anymore. If the treating physician determines the care is medically necessary because of a congenital anomaly affecting the eyes, ears, teeth, mouth, or jaw, the plan has to cover it. That includes the original surgeries, complications, dental and orthodontic support tied to the defect, prosthetics, and follow-up treatment for secondary conditions.

The bill stretches coverage across the full course of treatment — from birth until the medical work is done — and bars insurers from charging stiffer copays or deductibles for this care than they apply to other medical services. It also amends three different laws (the Public Health Service Act, ERISA, and the tax code) so the requirements reach employer plans, individual plans, and self-funded plans alike.

The bill draws one line: it does not require coverage of cosmetic surgery on normal body structures done purely to improve appearance or self-esteem when there is no medical determination of a birth defect. The fight in committee will be over where insurers, doctors, and HHS draw the boundary between medically necessary reconstruction tied to a congenital anomaly and excluded cosmetic work — and how much premium pressure the new coverage adds.