All private group and individual health insurance plans would be required to cover medically necessary services resulting from birth defects under bipartisan federal legislation introduced recently in both the House and Senate.

The Ensuring Lasting Smiles Act – championed by the American Association of Oral and Maxillofacial Surgeons (AAOMS) – was re-introduced March 16 by US Sens Tammy Baldwin (D-Wis) and Joni Ernst (R-Iowa) along with US Reps Anna Eshoo (D-Calif) and Drew Ferguson (R-Ga), who also is a dentist.

Address Delays and Denials

The legislation (S 754/HR 1916) would address delays and denials in coverage (including plans regulated by the Employee Retirement Income Security Act of 1974) to ensure patients suffering from birth defects, also known as congenital anomalies, receive the treatment they need in a timely manner. These treatments could include adjunctive dental, orthodontic or prosthodontic support. The bill excludes coverage for cosmetic surgery to reshape normal structures of the body to improve appearance or self-esteem. 

While many private health insurance companies cover preliminary procedures for congenital anomalies, they routinely deny or delay follow-up or corrective procedures – notably, dental-related procedures involving orthodontia and dental implants – deeming them cosmetic or covered by dental plans.

Severe dental anomalies are a common symptom of many craniofacial anomaly conditions, but coverage limits in dental plans are not nearly as robust as that of health plans. As a result, patients are often forced to incur significant out-of-pocket costs on medically necessary reconstructive dental care related to their disorder during their lifetime, a media release from AAOMS explains.

“AAOMS is passionate about advocating for health coverage on behalf of our patients with craniofacial anomalies. We were disappointed that – despite more than 300 bipartisan House cosponsors and 50 bipartisan Senate cosponsors – the 116th Congress did not pass the bill. We look forward to working with the bill sponsors and other patient and provider organizations to get this bill over the finish line this Congress.”

— AAOMS President B.D. Tiner, DDS, MD, FACS

Aims to Cover Congenital Surgery

The Centers for Disease Control and Prevention classifies birth defects as “common, costly and critical” and reports that one in 33 US newborns suffers from a congenital anomaly. Craniofacial anomalies – deformities in the growth of the bones in the head and face – can restrict a patient’s ability to breathe, eat and speak. Early intervention by a team of specialists – including oral and maxillofacial surgeons, plastic surgeons, pediatric dentists, orthodontists, dermatologists and speech therapists – is regarded as necessary to assess and oversee the patient’s treatment and development, often over the course of many years.

Sens. Baldwin and Ernst sponsored this important legislation in the last Congress. Reps. Eshoo and Ferguson were brought on as new lead sponsors in the House. For Rep. Ferguson, the issue hits close to home, per the release.

“As a practicing dentist for nearly 25 years, building better smiles was my career, and it continues to be a top priority of mine in Congress. The Ensuring Lasting Smiles Act would require all private, individual healthcare plans to cover medically necessary dental services, including reconstructive surgeries that are a result of congenital anomalies or birth defects.

“This life-changing bill will give families the opportunity to save for their children’s futures by addressing a loophole that has long allowed insurance companies to routinely deny oral or dental claims for medically necessary treatments.”

— Drew Ferguson (R-Ga)

The Ensuring Lasting Smiles Act is supported by more than 30 health professional and patient advocacy organizations, including AAOMS, the National Foundation for Ectodermal Dysplasias, American Society of Plastic Surgeons, American College of Surgeons, American Dental Association and National Organization for Rare Disorders. 

[Source(s): American Association of Oral and Maxillofacial Surgeons, PR Newswire]

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