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Groups support bill requiring private health plans to cover medically necessary services

March 01, 2019

By Jennifer Garvin

Washington — The ADA is one of 35 organizations supporting the Ensuring Lasting Smiles Act — legislation that would require all private group and individual health plans to cover medically necessary services that repair or restore congenital anomalies.

In a Feb. 28 letter to Sens. Tammy Baldwin, D-Wis., and Joni Ernst, R-Iowa, and Reps. Collin Peterson, D-Minn., and Denver Riggleman, R-Va., the organizations told the legislators they believe the Ensuring Lasting Smiles Act, or ELSA, would positively impact the quality of life for patients with congenital anomalies and also eliminate the existing burdens that prevent access to necessary diagnosis and treatment. Support for the bill was spearheaded by the American Association of Oral and Maxillofacial Surgeons and lead partners were the American Society of Plastic Surgeons, the National Foundation for Ectodermal Dysplasias, and the American Association of Orthodontists.

Sens. Baldwin and Ernst, along with Sens. Sherrod Brown, D-Ohio, and Lisa Murkowski, R-Alaska, reintroduced the ELSA Act (S 560) reintroduced the bill to the 116th Congress on Feb. 26. The House version of the bill (HR 1379) was also introduced Feb. 26.

“We appreciate your leadership in recognizing the importance of ensuring access to the care and services necessary to improve or restore body function or approximate a normal appearance due to a congenital anomaly, such as cleft lip and palate, skeletal and maxillofacial abnormalities, facial paralysis, microtia, hypodontia, and craniosynostosis,” they wrote.

The groups pointed out that the Centers for Disease Control and Prevention classifies birth defects as “common, costly, and critical” and reports that one in 33 newborns in the United States is born with a congenital anomaly.

“Craniofacial anomalies, for example, can restrict a patient’s ability to breathe, eat and speak in a normal manner,” the organizations said. “Therefore, highly personalized surgery to repair an anomaly helps the patient grow and function normally. Early intervention by a team of specialists, including plastic surgeons, oral and maxillofacial surgeons, pediatric dentists, orthodontists, dermatologists, and speech therapists, is necessary to assess and oversee the patient’s treatment and development, sometimes over the course of several years.”

The groups also said that while many private health insurance companies cover preliminary procedures, they “routinely deny or delay follow-up or corrective procedures claiming that they are cosmetic in nature — which fails to recognize the medical conditions of these patients.”

“Delays in medically necessary care can negatively impact a child’s developmental milestones and coverage denials of a child’s reconstructive surgery, can result in families turning to Medicaid, the State Children's Health Insurance Program, or other safety net programs for coverage,” they wrote.

Follow all of the ADA’s advocacy efforts at ADA.org/advocacy.