Sponsors (155)
The bill expands mandatory coverage and transparency to improve access and reduce some out-of-pocket costs for people with congenital craniofacial and related anomalies, but it raises insurance costs and administrative complexity and may still leave some patients facing substantial cost-sharing or disputes over medical necessity.
People born with congenital anomalies of the eyes, ears, teeth, mouth, or jaw (including children and ongoing patients) will have required coverage from birth through treatment completion for medically necessary diagnostic, reconstructive, dental/orthodontic/prosthodontic, and follow-up care.
Insured individuals—especially low-income people and those with chronic conditions—are likely to face lower out-of-pocket costs for these medically necessary services because plans must cover them and cannot impose cost‑sharing more restrictive than prevailing medical/surgical cost‑sharing.
Patients and families gain clearer information and federal oversight: plans must notify participants of the coverage rules by Jan 1, 2026, and HHS must study and report (by Dec 31, 2027) on network adequacy and cost impacts to inform future policy and access improvements.
Employers, insurers, and individual policyholders may face higher premiums and overall insurance costs because plans will incur additional mandatory benefit obligations.
Low-income individuals and people whose plans have high prevailing medical/surgical cost‑sharing may still face substantial out-of-pocket expenses because the law permits cost‑sharing up to the plan’s dominant medical/surgical levels.
Hospitals, health systems, insurers, and state regulators may face increased administrative complexity coordinating dental/orthodontic/prosthodontic services that are often managed under separate dental benefits, complicating billing and coverage implementation.
Based on analysis of 2 sections of legislative text.
Requires group and individual health plans to cover medically necessary diagnosis, reconstructive, and dental/orthodontic/prosthodontic treatment for congenital anomalies affecting eyes, ears, teeth, mouth, or jaw.
Introduced May 8, 2025 by Neal Patrick Dunn · Last progress May 8, 2025
Requires group and individual health plans and issuers to cover outpatient and inpatient diagnosis and treatment services for congenital anomalies or birth defects that primarily affect the appearance or function of the eyes, ears, teeth, mouth, or jaw. Coverage must include medically necessary reconstructive procedures, related complication care, and dental/orthodontic/prosthodontic support from birth through completion of treatment; cosmetic surgery unrelated to a medical determination of a congenital anomaly is excluded. Plans may apply cost‑sharing but not more restrictively than the plan’s predominant medical/surgical cost‑sharing, and plans/issuers must begin certain participant notifications on January 1, 2026.