Ensuring Lasting Smiles Act
- Bill Number
- H.R. 3277
- Origin Chamber
- House
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2025-05-08: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- Last Updated
- 2026-07-07T08:05:52Z
AI-Generated Summary
Purpose
The Ensuring Lasting Smiles Act (H.R. 3277) aims to ensure that health insurance plans cover medical treatments for congenital anomalies or birth defects—conditions present at birth that affect the structure or function of body parts—specifically those impacting the eyes, ears, teeth, mouth, or jaw. It seeks to improve access to reconstructive and supportive care, including dental and orthodontic services, to help restore normal function or appearance.
Key Provisions
- Mandatory Coverage: Group health plans and health insurance issuers (companies that sell health coverage) must provide benefits for outpatient and inpatient items and services related to diagnosing and treating congenital anomalies or birth defects affecting the eyes, ears, teeth, mouth, or jaw. This includes:
- Medically necessary procedures to repair, restore, or approximate normal body function or appearance, as determined by the treating physician.
- Treatments for missing or abnormal body parts, such as reconstructive surgeries, handling of complications, adjunctive dental/orthodontic/prosthodontic support (e.g., braces or dental prosthetics) from birth until treatment is complete, and follow-up care for secondary conditions.
- Cost-Sharing Limits: Any patient costs (like copays, coinsurance, or deductibles—out-of-pocket fees) cannot be more restrictive than those applied to most other medical or surgical benefits under the plan.
- Exceptions: Coverage does not extend to cosmetic surgery that reshapes normal body structures solely to improve appearance or self-esteem, unless linked to a congenital anomaly.
- Notice Requirement: Starting January 1, 2026, plans and issuers must inform participants and beneficiaries about this coverage in documents describing services, following guidelines from the Secretary of Health and Human Services (HHS).
- Definition of Congenital Anomaly or Birth Defect: A prenatal structural or functional abnormality that may arise from genetic factors, environmental influences, nutrient issues, or unknown causes; it can appear as physical disabilities, syndromes, or other health problems and may be identified before, at, or after birth.
- Study and Report: HHS must conduct a study on provider network adequacy (sufficiency and accessibility of specialists) for these treatments and report to Congress by December 31, 2027. The report will also assess changes in patient out-of-pocket costs and overall procedure costs due to the new requirements.
- Legal Amendments: Adds parallel sections to three key laws:
- Public Health Service Act (governing individual and group health insurance).
- Employee Retirement Income Security Act (ERISA, which regulates employer-sponsored plans).
- Internal Revenue Code (affecting tax-qualified health plans).
- Effective Date: Applies to plan years starting on or after January 1, 2026.
Significant Changes to Existing Law
- Introduces new mandatory coverage requirements in federal health laws, overriding common exclusions for dental, orthodontic, or prosthodontic services in health plans when those services address congenital anomalies (even if typically excluded for other conditions like injuries).
- Expands beyond general reconstructive surgery mandates (e.g., under the Affordable Care Act) by specifically targeting craniofacial (head and face) birth defects and requiring lifelong support in some cases.
- Adds enforcement through the existing frameworks of the Public Health Service Act, ERISA, and the Internal Revenue Code, including technical updates to reference the new sections.
Potential Impacts
- On Citizens: Improves access to essential treatments for individuals (especially children) with craniofacial birth defects, potentially reducing long-term health issues, improving quality of life, and lowering personal financial burdens from uncovered care. However, it may lead to higher premiums if costs are passed on by insurers.
- On Government Agencies: HHS will oversee implementation, notices, and the required study/report, increasing administrative workload. No direct funding is appropriated, so enforcement relies on existing resources.
- On Health Insurers and Employers: Insurers must update plans and networks, potentially raising operational costs; employers sponsoring plans may face higher premiums but benefit from standardized coverage.
- On International Relations: Minimal impact, as this is a domestic health insurance reform with no foreign policy elements.
Main Stakeholders Affected
- Individuals and Families: Primarily those with congenital anomalies affecting the eyes, ears, teeth, mouth, or jaw (e.g., cleft palate, missing teeth, or jaw deformities), including children needing ongoing care.
- Health Insurance Issuers and Group Health Plans: Required to provide and fund the new coverage, affecting private insurers and self-insured employer plans.
- Employers: As sponsors of group plans under ERISA, they may see cost implications for employee benefits.
- Healthcare Providers: Specialists in reconstructive surgery, dentistry, orthodontics, and related fields (e.g., oral surgeons, ENT doctors) gain clearer reimbursement paths but must ensure medical necessity documentation.
- Federal Agencies: HHS for regulation, study, and enforcement; Congress for oversight via the report.
Notable Legal, Constitutional, or Political Implications
- Legal: Strengthens patient protections similar to Affordable Care Act (ACA) essential health benefits by filling gaps in craniofacial care; relies on "medically necessary" determinations by physicians (defined under Social Security Act as a doctor providing care), which could lead to disputes resolved through plan appeals or HHS regulations. No private right of action is created, so enforcement is administrative.
- Constitutional: Aligns with Congress's authority to regulate interstate commerce and health insurance under the Commerce Clause; no apparent free speech, privacy, or equal protection issues, as it applies uniformly to covered plans.
- Political: Bipartisan support evident from diverse cosponsors (Republicans and Democrats), suggesting broad appeal for child health issues. Could influence future expansions of ACA-like mandates but may face opposition from insurers over costs; the study provision allows for data-driven adjustments without immediate fiscal mandates.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (167)
Rep. Schrier, Kim [D-WA-8], Rep. Aderholt, Robert B. [R-AL-4], Rep. Babin, Brian [R-TX-36], Rep. Salazar, Maria Elvira [R-FL-27], Rep. Gosar, Paul A. [R-AZ-9], Rep. Nehls, Troy E. [R-TX-22], Rep. Yakym, Rudy [R-IN-2], Rep. Moore, Gwen [D-WI-4], Rep. Dingell, Debbie [D-MI-6], Del. Norton, Eleanor Holmes [D-DC-At Large], Rep. Tlaib, Rashida [D-MI-12], Rep. Landsman, Greg [D-OH-1], Rep. Fields, Cleo [D-LA-6], Rep. Bonamici, Suzanne [D-OR-1], Rep. Mrvan, Frank J. [D-IN-1], Rep. Quigley, Mike [D-IL-5], Rep. Mannion, John W. [D-NY-22], Rep. Lynch, Stephen F. [D-MA-8], Rep. Omar, Ilhan [D-MN-5], Rep. Houlahan, Chrissy [D-PA-6], Rep. Tokuda, Jill N. [D-HI-2], Rep. Neguse, Joe [D-CO-2], Rep. Stanton, Greg [D-AZ-4], Rep. Pocan, Mark [D-WI-2], Rep. Bost, Mike [R-IL-12], Rep. Castro, Joaquin [D-TX-20], Rep. Chu, Judy [D-CA-28], Rep. Craig, Angie [D-MN-2], Rep. Wasserman Schultz, Debbie [D-FL-25], Rep. Davis, Donald G. [D-NC-1], Rep. Kelly, Robin L. [D-IL-2], Rep. Johnson, Julie [D-TX-32], Rep. Levin, Mike [D-CA-49], Rep. Ryan, Patrick [D-NY-18], Rep. Davids, Sharice [D-KS-3], Rep. Pappas, Chris [D-NH-1], Rep. DelBene, Suzan K. [D-WA-1], Rep. Auchincloss, Jake [D-MA-4], Rep. Nunn, Zachary [R-IA-3], Rep. Olszewski, Johnny [D-MD-2], Rep. Vindman, Eugene Simon [D-VA-7], Rep. Rutherford, John H. [R-FL-5], Rep. Magaziner, Seth [D-RI-2], Rep. McBride, Sarah [D-DE-At Large], Rep. Krishnamoorthi, Raja [D-IL-8], Rep. Panetta, Jimmy [D-CA-19], Rep. Simpson, Michael K. [R-ID-2], Rep. Matsui, Doris O. [D-CA-7], Rep. Amo, Gabe [D-RI-1], Rep. Castor, Kathy [D-FL-14] and 117 more
Recent Actions
- 2025-05-08: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- 2025-05-08: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- 2025-05-08: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
- 2025-05-08: Introduced in House
- 2025-05-08: Introduced in House
Bill Versions
- Ensuring Lasting Smiles Act — issued 2025-05-08 — PDF (16 pages)