Dental and Facial Birth Defect Coverage Mandated Starting 2026: What the 'Ensuring Lasting Smiles Act' Means for Families

The new Ensuring Lasting Smiles Act requires health plans to cover diagnosis and treatment for congenital anomalies or birth defects that affect the function or appearance of the eyes, ears, teeth, mouth, or jaw. This isn’t just about medical care; it mandates coverage for necessary reconstructive procedures and related dental/orthodontic support from birth until the treatment is complete.

The Fine Print: Fixing Function and Form

Starting in plan years on or after January 1, 2026, if you have a group health plan or individual coverage, the rules are changing. The bill, applied across major federal laws (ERISA, PHSA, and the Internal Revenue Code), states that if a doctor determines a treatment is medically necessary to fix, improve, or restore a body part affected by a birth defect—whether it’s structural or functional—the insurance plan has to cover it. This is huge because it closes a common loophole: many plans currently exclude dental or orthodontic work, even when it's essential for fixing a congenital issue like a cleft palate or severe jaw misalignment.

For example, imagine a child born with a condition requiring multiple surgeries and years of specialized orthodontics to eat and speak normally. Under current rules, the surgical part might be covered, but the essential, multi-year orthodontic work often gets denied as 'cosmetic' or 'dental exclusion.' This Act explicitly requires coverage for that necessary dental, orthodontic, or prosthetic support until the main treatment is finished. The only thing they don't have to cover is purely cosmetic surgery done just to change the appearance of normal body parts.

What About the Cost?

This new mandate is great news for the families directly affected, who often face staggering bills for these complex, long-term treatments. The bill requires that any cost-sharing (deductibles, copays) for these birth defect treatments can’t be any tougher than what the plan charges for most other medical and surgical care. This means your plan can’t slap a massive, specialized copay on these services just because they’re expensive.

However, there’s always a trade-off. When the government mandates broader coverage, insurance companies inevitably pass those costs along. For the average policyholder—the 35-year-old software engineer or the 40-year-old electrician—you may see a slight bump in your overall premiums. It’s the classic insurance balancing act: a few people need very expensive, specialized care, and everyone else contributes a little bit to make sure that care is available.

The Implementation Check

To make sure this new coverage is actually usable, the bill also mandates that the Secretary of Health and Human Services perform a study by December 31, 2027. This study will look at two critical things: first, whether there are actually enough specialists (like craniofacial surgeons and specialized orthodontists) in existing provider networks to handle the increased demand; and second, how these new mandates affect patients' out-of-pocket costs. If networks are too thin, having coverage doesn’t help much if the nearest specialist is five states away and out-of-network. This study is a necessary check to ensure the new rules deliver real access, not just paper promises.