Summary
Makes health insurance plans cover medically necessary treatments for birth defects affecting the eyes, ears, teeth, mouth, or jaw.
What problem does this solve?
Some health insurance plans refuse to pay for treatments for birth defects, calling them cosmetic. This bill requires insurance to cover medically necessary care to fix problems with how a person's body works or looks due to a birth defect.
Who does this affect?
- Individuals born with congenital anomalies
- Families of individuals with congenital anomalies
- Health insurance providers
What does this bill do?
Reference
Text:
Section:
Sec. 2799A-11(a)(1)
Header:
Requirements for care and reconstructive treatment
Mandates coverage for birth defects
Requires group and individual health insurance plans to cover the diagnosis and treatment of birth defects that affect the eyes, ears, teeth, mouth, or jaw.
Includes dental and orthodontic care
Ensures coverage includes necessary dental, orthodontic, or prosthodontic support from birth until treatment is complete, even if the plan normally excludes such services.
Limits patient costs
Prevents insurance plans from charging higher co-pays, deductibles, or other fees for these services than they do for most other medical and surgical benefits.
Excludes purely cosmetic surgery
Clarifies that the required coverage does not include cosmetic surgery on normal body parts just to improve appearance or self-esteem.
Requires a government study on care access
Directs the government to study how easy it is for patients to find doctors for these treatments and how the new rules affect costs for patients and procedures.
Defines what counts as a birth defect
Provides a broad definition for 'congenital anomaly or birth defect' to include a wide range of structural or functional issues that develop before birth.
What is the real world impact?
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Reduces large medical bills for families
Ensures that families with children born with birth defects do not have to pay for expensive, but medically necessary, surgeries and treatments all by themselves. This helps prevent families from going into debt for their child's care.
When does this start?
The new insurance rules will apply to health plans starting on or after January 1, 2026, with other deadlines also set.
Effective date for new coverage
The requirement for health plans to cover these services applies to plan years that begin on or after January 1, 2026.
Notice to insurance members
Health insurance plans must start telling their members about this new coverage by January 1, 2026.
Report to congress deadline
The Secretary of Health and Human Services must complete a study on care access and costs and report the findings to Congress by December 31, 2027.