Sponsors (146)
The bill expands required, continuous coverage for medically necessary diagnosis and reconstructive/dental care for people with congenital anomalies and increases transparency, but it may raise premiums, leave some out-of-pocket and access gaps, and permit administrative or cosmetic exclusions that limit coverage for certain patients.
Children and adults with congenital anomalies will gain required coverage for medically necessary diagnosis, reconstructive surgery, and dental/orthodontic/prosthodontic supports from birth until treatment completion, including follow-up care and treatment of secondary conditions.
Patients with congenital anomalies are protected from discriminatory cost-sharing rules: plans must not impose more restrictive coinsurance or deductibles for these required benefits than for predominant medical/surgical benefits.
Beneficiaries and policymakers get improved transparency and information—plans must notify enrollees by Jan 1, 2026 about covered services, and HHS will study network adequacy and cost impacts to inform future policy.
Insured individuals and employers could face higher premiums if the expanded mandated coverage raises overall plan costs.
Some patients may still incur significant out-of-pocket expenses because cost-sharing can remain for covered services despite the nondiscrimination rule.
Patients—particularly in rural areas—may have limited access to necessary specialists if provider networks are inadequate, forcing travel or delays for reconstructive or dental services.
Based on analysis of 2 sections of legislative text.
Introduced May 8, 2025 by Neal Patrick Dunn · Last progress May 8, 2025
Requires group health plans and health insurance issuers to cover medically necessary outpatient and inpatient services to diagnose and treat congenital anomalies or birth defects that primarily affect the appearance or function of the eyes, ears, teeth, mouth, or jaw. Coverage must include reconstructive surgery, related complication care, supportive dental/orthodontic/prosthodontic services from birth until treatment is complete, and follow-up care; cosmetic procedures not medically related to a defect are excluded. Plans may apply cost-sharing but cannot make cost-sharing for these benefits more restrictive than the predominant cost-sharing for other medical and surgical benefits. Plans and issuers must notify participants about the coverage requirement by January 1, 2026. The law takes effect for plan years beginning on or after January 1, 2026, and directs HHS to study network adequacy and cost impacts and report to Congress by December 31, 2027.