Ensuring Lasting Smiles Act

Mandated Coverage for Essential Care: Group health plans and health insurance issuers must provide coverage for outpatient and inpatient items and services related to the diagnosis and treatment of congenital anomalies or birth defects that impact the eyes, ears, teeth, mouth, or jaw (Section 2, a, 1).

Protection Against Excessive Out-of-Pocket Costs: Cost-sharing requirements, such as copayments or deductibles, cannot be more restrictive than the predominant cost-sharing applied to other medical and surgical benefits under the plan (Section 2, a, 2).

Comprehensive Reconstructive Support: The bill requires coverage for items or services meant to improve, repair, or restore body parts to achieve normal functioning or appearance, as determined medically necessary (Section 2, a, 3, A, i).

Continued Dental and Orthodontic Care: Coverage includes adjunctive dental, orthodontic, or prosthodontic support from birth until the medical or surgical treatment of the defect is completed (Section 2, a, 3, A, ii, II).

Follow-up Care Inclusion: The mandate extends to items and services related to secondary conditions and follow-up treatment associated with the underlying congenital anomaly or birth defect (Section 2, a, 3, A, iii).

Informed Beneficiaries: Insurers are required to provide notice to participants and beneficiaries regarding these coverage requirements in their service documents by January 1, 2026 (Section 2, a, b).