ROSEMONT, Ill. – 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 Tuesday in both the House and Senate.
The Ensuring Lasting Smiles Act – advocated and advanced by the American Association of Oral and Maxillofacial Surgeons (AAOMS) was introduced by U.S. Sens. Tammy Baldwin (D-Wis.) and Joni Ernst (R-Iowa) along with U.S. Reps. Collin Peterson (D-Minn.) and Denver Riggleman (R-Va.).
The legislation (S 560 / HR 1379) would address delays and denials in coverage (including plans regulated by ERISA) to ensure that 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 does exclude 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.
“AAOMS is pleased to have played a leading role in working with the bill sponsors and other patient and provider organizations to bring this issue to the forefront,” said AAOMS President A. Thomas Indresano, DMD, FACS. “A family trying to improve its loved one’s life should not have to face the added trauma of battling their insurance company.”
The Centers for Disease Control and Prevention (CDC) classifies birth defects as “common, costly, and critical” and reports that 1 in 33 U.S. 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.
Sen. Baldwin has worked to introduce the legislation since learning about 13-year-old Aidan Abbott of Slinger, Wis., who was born with the rare congenital anomalyectodermal dysplasia. He has needed extensive dental and oral care and will undergo future reconstructive surgeries. Even with comprehensive health insurance, his family was denied coverage for Aidan’s dental care and had to pay out of pocket.
“Aidan’s story has inspired my work on this issue to guarantee that individuals born with congenital anomalies have access to the comprehensive health treatments and coverage they need and deserve,” Sen. Baldwin said. “Despite covering all of his other medical care, his family’s insurance continues to refuse to cover his dental care needs, forcing them to spend thousands of dollars out of their own pockets. That’s why I’m introducing bipartisan legislation to close this loophole and make sure families like Aidan’s can get the healthcare they need at a price they can afford.”
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, National Organization for Rare Disorders and March of Dimes.