American Society of Plastic Surgeons
For Consumers

ASPS Continues to Advocate for Congenital Anomaly Coverage

As ASPS continues its advocacy for increased congenital anomaly coverage at the federal level through the Ensuring Lasting Smiles Act (ELSA), support for similar legislation at the state level has begun to grow throughout the country.

While state-level congenital anomaly legislation is in various stages – some legislative concepts are in the early stages of development and other states have enacted laws – ASPS is monitoring these proposals closely in various legislative chambers and actively working to support efforts in conjunction with local, state and regional plastic surgery societies.

The issue

Children with a congenital anomaly or birth defect or disorder who do not receive treatment at an early age face long-term physical and psychological injuries. Despite the ability of reconstructive surgical efforts to improve the outlook for these children, many insurers often claim that these services are "cosmetic" in nature, especially subsequent stage surgeries. However, the American Medical Association defines surgery performed on abnormal structures of the body caused by congenital defects or developmental abnormalities as reconstructive, not cosmetic. Furthermore, insurers frequently overlook the dental and orthodontic needs of these patients – which are essential to their achieving normal form and function – and mislead affected patients and the public when deeming these procedures cosmetic.

Children who undergo surgery to address congenital anomalies can generally expect to have between three and five surgical procedures throughout their childhood to try and restore a more normal appearance and function.

Additionally, insurance coverage denials of a child's reconstructive care can force patient families to turn to Medicaid, SCHIP or other government safety net programs for health care coverage. If they cannot receive coverage through those programs, they are often forced to incur significant out-of-pocket costs or forgo care.

Leading the charge at the federal level

ASPS has been a leading advocate on the federal issue of congenital anomaly coverage across many years and sessions of Congress. The Society's efforts to expand coverage have recently come in the form of the Ensuring Lasting Smiles Act (ELSA) – a bill ASPS worked to craft with Senator Tammy Baldwin (D-WI) under the leadership of Dr. Arun Gosain, then president of the Plastic Surgery Foundation (PSF) and a Wisconsin plastic surgeon specializing in surgical correction of craniofacial and vascular anomalies.

A longtime federal priority for ASPS, ELSA would require all private group and individual health plans (including plans regulated by the Employee Retirement Income Security Act of 1974 (ERISA)) to cover medically necessary items or services resulting from congenital anomalies or birth defects. It also stipulates that such coverage includes items and services to functionally improve, repair or restore any body part that is medically necessary to achieve normal body functioning or appearance, and clarify the inclusion of adjunctive dental, orthodontic or prosthodontic support.

In 2018, the Society formed the ELSA Coalition with the American Association of Oral and Maxillofacial Surgeons (AAOMS) and the National Foundation for Ectodermal Dysplasia (NFED). The Coalition's membership has now grown to more than 35 patient advocacy and medical groups.

Since the introduction of ELSA, ASPS has been committed to advancing the legislation – executing dozens of formal communications and grassroots campaigns that connected hundreds of ASPS members with their representatives; conducting nearly 300 face-to-face meetings with members of Congress and their staff; educating dozens of members of Congress and candidates for office about the issue through PlastyPAC member meetings; partnering with state plastic surgery societies to support the legislation through letters and written testimony; and continuing to work with the sponsors and committee staff to identify studies and key data to help the Congressional Budget Office (CBO) accurately score the bill's financial impact.

While ELSA has faced numerous hurdles to enactment and efforts to pass the landmark legislation have been unsuccessful in previous sessions of Congress, ELSA was reintroduced in the US House and Senate on March 16 by Senators Tammy Baldwin and Joni Ernst (R-IA), and Representatives Anna Eshoo (D-CA) and Drew Ferguson IV, DDS (R-GA). This current iteration of the bicameral legislation has strong bipartisan support in the 117th Congress and remains one of the Society's top priorities.

State-level efforts to expand coverage

A recent groundswell of support for increased congenital anomaly coverage at the state level has renewed interest in the issue with lawmakers and raised awareness within the broader public.

The New York State Society of Plastic Surgeons (NYSSPS) launched a campaign to expand coverage for children with congenital anomalies dubbed, "1 in 38: The Campaign to Give Kids a Chance." Named for the statistic that in New York, 1 in 38 babies are born with a congenital anomaly, the campaign seeks to mandate health insurance coverage for congenital anomalies including certain reconstructive services, habilitative services and inpatient and outpatient services. NYSSPS initiated a call for action asking its members to urge state lawmakers to expand coverage. The grassroots effort also called on the NYS Department of Financial Services to create new regulations that would also correct regulations governing insurance companies and their coverage of congenital anomalies.

A legislative concept in Massachusetts still in the early stages of development would, "provide health insurance coverage for certain medically necessary functional repair or restoration of craniofacial disorders." While the bill has been in committee since March, the General Court of the Commonwealth of Massachusetts remains in session and ASPS will continue to monitor the bill.

In a significant win for the movement toward expanded coverage, the Arkansas State Legislature passed key amendments to a 2013 law requiring insurance companies to cover corrective surgical procedures and treatment for people with craniofacial anomalies determined by a "nationally accredited cleft-craniofacial team." Wendelyn's Craniofacial Law clarifies the definition of "Craniofacial anomaly" among other key changes for the purpose of ensuring adequate coverage for patients.

Ongoing advocacy

ASPS remains committed to ensuring children have adequate insurance coverage to treat congenital or birth abnormalities and will continue to work closely with lawmakers, staff, coalition partners and local, state and regional partners to advance ELSA and state legislation to provide much needed relief to families dealing with congenital anomalies.