Bill H.5041

FILED ON: 1/23/2026

HOUSE . . . . . . . . . . . . . . . No. 5041

The Commonwealth of Massachusetts

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In the One Hundred and Ninety-Fourth General Court
(2025-2026)

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An Act relative to ensuring treatment for genetic craniofacial conditions.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:

SECTION 1. Chapter 32A of the General Laws is hereby amended by inserting after section 17Z the following section:-

Section 17AA. Any coverage offered by the commission to an active or retired employee of the commonwealth insured under the group insurance commission shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders, with the exception of coverage for cleft lip and cleft palate which is prescribed under section 17J , to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of ectodermal dysplasia, dentinogenesis imperfecta and amelogenesis imperfecta. Coverage under this section shall not include cosmetic surgery or for dental or orthodontic treatment unrelated to said congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the commission.

SECTION 2. Chapter 118E of the General Laws is hereby amended by inserting after section 10Z the following section:-

Section 10AA. The division shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed pursuant to section 10G, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of ectodermal dysplasia, dentinogenesis imperfecta and amelogenesis imperfecta. Coverage under this section shall not include cosmetic surgery or for dental or orthodontic treatment unrelated to said congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the division.

SECTION 3. Chapter 175 of the General Laws is hereby amended by inserting before section 47CCC the following section:-

Section 47AAA. Any blanket or general policy of insurance described in subdivision (A), (C), or (D) of section one hundred and ten which is issued or subsequently renewed by agreement between the insurer and the policyholder, within or without the commonwealth, during the period within which this premium is effective, or any policy of accident or sickness insurance as described in section one hundred and eight which provides hospital expense and surgical expense insurance and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policyholder in the commonwealth, during the period within which this provision is effective, or any employers' health and welfare fund which provides hospital expense and surgical expense benefits and which is issued or renewed to any person or group of persons in the commonwealth, during the period within which this provision is effective, shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed under section 47BB, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of ectodermal dysplasia, dentinogenesis imperfecta and amelogenesis imperfecta. Coverage under this section shall not include cosmetic surgery or dental or orthodontic treatment unrelated to said congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION 4. Chapter 176A of the General Laws is hereby amended by inserting after section 8DDD the following section:-

Section 8EEE. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed pursuant to section 8EE of this section, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of ectodermal dysplasia, dentinogenesis imperfecta and amelogenesis imperfecta. Coverage under this section shall not include cosmetic surgery or dental or orthodontic treatment unrelated to said congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION 5. Chapter 176B of the General Laws is hereby amended by inserting after section 4DDD the following section:-

Section 4EEE. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of ectodermal dysplasia, dentinogenesis imperfecta and amelogenesis imperfecta. Coverage under this section shall not include cosmetic surgery or dental or orthodontic treatment unrelated to said congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION 6. Chapter 176G of the General Laws is hereby amended by inserting after section 4VV the following section:-

Section 4WW. Any individual or group health maintenance contract shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed under section 4W of this chapter, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of ectodermal dysplasia, dentinogenesis imperfecta and amelogenesis imperfecta. Coverage under this section shall not include cosmetic surgery or dental or orthodontic treatment unrelated to said congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION 7. Chapter 176I of the General Laws is hereby amended by inserting after section 13 the following section:-

Section 14 An organization entering into a preferred provider contract shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed under section 12 of this chapter, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly, including, ectodermal dysplasia, dentinogenesis imperfecta, and amelogenesis imperfecta. Coverage under this section shall not include cosmetic surgery or dental or orthodontic treatment unrelated to congenital defects, developmental deformities, trauma, tumors, infections or disease. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.