Ensuring Lasting Smiles Act

ASPS is leading the fight to pass the Ensuring Lasting Smiles Act, federal legislation that would require all group and individual health plans to cover medically necessary reconstructive procedures to treat a patient's congenital anomaly. In February 2019, Senators Tammy Baldwin (D-WI) and Joni Ernst (R-IA) reintroduced the Ensuring Lasting Smiles Act in the Senate, and shortly after Representatives Collin Peterson (D-MN) and Denver Riggleman (R-VA) reintroduced the bill in the House. The Society first pledged its support for the bill when introduced in 2018 and will continue to advocate for passage of this legislation in the 116th Congress.

Bill Summary

The Ensuring Lasting Smiles Act is bipartisan legislation in Congress that would:

• Ensure that all private group and individual health care plans cover medically necessary services including reconstructive surgeries as a result of congenital anomalies;
• Require that insurance coverage includes services and procedures that repair function or restore any missing body part that is medically necessary to achieve a normal appearance or function of the body;
• Protect patients against increased insurance premiums by clearly stipulating that coverage may be subject to limits, such as pre-authorization or pre-certification, as long as those limits are no more restrictive than for any other injury or sickness
• Exclude health care coverage for cosmetic surgery to reshape normal structures of the body to improve physical appearance

Why is legislation needed?

Insurance companies regularly cover the preliminary procedures to treat congenital anomalies, but often deny and delay follow-up reconstructive procedures, claiming they are cosmetic in nature. This places a significant burden on patients and their families who are often forced to resort to paying huge out-of-pocket costs, Medicaid for treatment coverage or, in worst case scenarios, terminate treatment.

In the United States, there are 25 states that require at least a minimum level of coverage for individuals with a craniofacial anomaly to address that significant, but very specific issue. However, these laws vary in requirements, and most are limited to craniofacial conditions. Currently, there is no federal requirement for coverage and a patchwork of different state policies on coverage. That is why federal legislation such as the Ensuring Lasting Smiles Act is needed to ensure uniform coverage for patients with all congenital anomalies.

More Resources

• Frequently Asked Questions
• Coalition Support Letter
• Senate Bill: S. 560
• House of Representatives Bill: H.R. 1379
• Press Release