Insurance Mandate: Health Plans Must Cover Reconstructive Care for Birth Defects Affecting Face, Teeth, and Eyes Starting 2026

The “Ensuring Lasting Smiles Act” is a major policy shift requiring most health insurance plans to cover extensive, long-term care for specific congenital anomalies or birth defects. Starting with plan years on or after January 1, 2026, group health plans and individual insurance policies must provide coverage for diagnosis and treatment related to birth defects that primarily affect the eyes, ears, teeth, mouth, or jaw (Section 2).

This isn’t just about basic medical care; it’s about covering the complex, often multi-year procedures needed to restore these body parts to look and function normally. Think of a child who needs a series of surgeries, specialized dental work, and orthodontics over a decade because of a cleft palate or other facial anomaly. This bill mandates that the insurance plan must cover the necessary outpatient and inpatient services, including diagnostic services and treatment for missing or abnormal parts resulting from the defect (Section 2).

The End of the Dental Loophole for Birth Defects

One of the most important changes here is how the bill handles dental and orthodontic care. Historically, insurance companies often denied coverage for these treatments by classifying them as routine dental work, which many medical plans exclude. This bill overrides that exclusion if the dental, orthodontic, or prosthetic support is needed because of the congenital anomaly and continues until the main treatment is finished. Crucially, it continues even if the treatment requires ongoing care to maintain function or appearance (Section 2). This means families won’t have to pay out-of-pocket for tens of thousands of dollars in specialized orthodontics that are medically necessary, not cosmetic, for the defect.

What It Means for Your Wallet (and Where the Catch Is)

For the average family facing these challenges, this is huge financial relief. These complex procedures can easily bankrupt a family over the course of a child’s life. However, the bill does not eliminate cost-sharing. Health plans can still apply standard cost-sharing rules—like deductibles, copayments, and coinsurance—as long as those financial requirements are no tougher than what the plan applies to most other medical and surgical benefits (Section 2). So, while the service is covered, a family could still hit their annual out-of-pocket maximum year after year, especially during intense treatment phases.

There’s also a clear line drawn on purely cosmetic procedures. If a surgery is only aimed at reshaping normal body structures to improve general appearance or self-esteem, and it’s not medically determined to be the result of the congenital anomaly, the plan doesn’t have to cover it (Section 2). This distinction between “restoration of function/appearance” and “purely cosmetic” is where disputes between patients, doctors, and insurers are likely to happen, especially given the medium vagueness level of the bill’s language in this area.

Implementation and the Provider Network Question

Implementation is set for early 2026, giving plans time to adjust. To ensure people can actually use this new coverage, the bill also mandates that the Secretary of Health and Human Services conduct a study on provider network access. They have until December 31, 2027, to report back to Congress on whether there are enough specialists available to treat these specific birth defects, and how the new coverage requirements might affect patient out-of-pocket costs (Section 2). This acknowledges a major practical challenge: even with mandated coverage, if the network of highly specialized surgeons and orthodontists is too small or geographically limited, access remains a problem, particularly for families living in rural areas.