Bill Text: NY A05053 | 2019-2020 | General Assembly | Introduced
Bill Title: Requires certain health insurance policies to include coverage for the cost of certain infant and baby formulas.
Spectrum: Strong Partisan Bill (Democrat 22-2)
Status: (Introduced - Dead) 2020-01-08 - referred to insurance [A05053 Detail]
Download: New_York-2019-A05053-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 5053 2019-2020 Regular Sessions IN ASSEMBLY February 7, 2019 ___________ Introduced by M. of A. JEAN-PIERRE, ZEBROWSKI, FERNANDEZ, ORTIZ, GUNTHER, ENGLEBRIGHT, WILLIAMS, PICHARDO, JOYNER, TAYLOR, MOSLEY, ARROYO, DICKENS, D'URSO, SIMON, GOTTFRIED, BARRON, COOK, McDONOUGH, PEOPLES-STOKES, MONTESANO, RICHARDSON -- Multi-Sponsored by -- M. of A. ABBATE -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to requiring certain health insurance policies to include coverage for the cost of certain infant and baby formulas The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Paragraph 21 of subsection (i) of section 3216 of the 2 insurance law, as amended by chapter 469 of the laws of 2018, is amended 3 to read as follows: 4 (21) Every policy which provides coverage for prescription drugs shall 5 include coverage for the cost of enteral, infant and baby formulas for 6 home use, whether administered orally or via tube feeding, for which a 7 physician or other licensed health care provider legally authorized to 8 prescribe under title eight of the education law has issued a written 9 order. Such written order shall state that the enteral, infant and baby 10 formula is clearly medically necessary and has been proven effective as 11 a disease-specific treatment regimen. Specific diseases and disorders 12 for which enteral, infant and baby formulas have been proven effective 13 shall include, but are not limited to, inherited diseases of amino acid 14 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux; 15 disorders of gastrointestinal motility such as chronic intestinal pseu- 16 do-obstruction; and multiple, severe food allergies including, but not 17 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies 18 to multiple food proteins; severe food protein induced enterocolitis 19 syndrome; eosinophilic disorders; and impaired absorption of nutrients 20 caused by disorders affecting the absorptive surface, function, length, 21 and motility of the gastrointestinal tract. Enteral, infant and baby EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD05414-02-9A. 5053 2 1 formulas which are medically necessary and taken under written order 2 from a physician for the treatment of specific diseases shall be distin- 3 guished from nutritional supplements taken electively. Coverage for 4 certain inherited diseases of amino acid and organic acid metabolism as 5 well as severe protein allergic conditions shall include modified solid 6 food products that are low protein or which contain modified protein, or 7 are amino acid based which are medically necessary, and such coverage 8 for such modified solid food products for any calendar year or for any 9 continuous period of twelve months for any insured individual shall not 10 exceed two thousand five hundred dollars. Coverage for infant and baby 11 formulas for any calendar year or any continuous period of twelve months 12 for any insured individual shall be no less than three thousand dollars. 13 § 2. Paragraph 11 of subsection (k) of section 3221 of the insurance 14 law, as amended by chapter 469 of the laws of 2018, is amended to read 15 as follows: 16 (11) Every policy which provides coverage for prescription drugs shall 17 include coverage for the cost of enteral, infant and baby formulas for 18 home use, whether administered orally or via tube feeding, for which a 19 physician or other licensed health care provider legally authorized to 20 prescribe under title eight of the education law has issued a written 21 order. Such written order shall state that the enteral, infant and baby 22 formula is clearly medically necessary and has been proven effective as 23 a disease-specific treatment regimen. Specific diseases and disorders 24 for which enteral, infant and baby formulas have been proven effective 25 shall include, but are not limited to, inherited diseases of amino-acid 26 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux; 27 disorders of gastrointestinal motility such as chronic intestinal pseu- 28 do-obstruction; and multiple, severe food allergies including, but not 29 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies 30 to multiple food proteins; severe food protein induced enterocolitis 31 syndrome; eosinophilic disorders and impaired absorption of nutrients 32 caused by disorders affecting the absorptive surface, function, length, 33 and motility of the gastrointestinal tract. Enteral, infant and baby 34 formulas which are medically necessary and taken under written order 35 from a physician for the treatment of specific diseases shall be distin- 36 guished from nutritional supplements taken electively. Coverage for 37 certain inherited diseases of amino acid and organic acid metabolism as 38 well as severe protein allergic conditions shall include modified solid 39 food products that are low protein or which contain modified protein, or 40 are amino acid based which are medically necessary, and such coverage 41 for such modified solid food products for any calendar year or for any 42 continuous period of twelve months for any insured individual shall not 43 exceed two thousand five hundred dollars. Coverage for infant and baby 44 formulas for any calendar year or any continuous period of twelve months 45 for any insured individual shall be no less than three thousand dollars. 46 § 3. Subsection (y) of section 4303 of the insurance law, as amended 47 by chapter 469 of the laws of 2018, is amended to read as follows: 48 (y) Every contract which provides coverage for prescription drugs 49 shall include coverage for the cost of enteral, infant and baby formulas 50 for home use, whether administered orally or via tube feeding, for which 51 a physician or other licensed health care provider legally authorized to 52 prescribe under title eight of the education law has issued a written 53 order. Such written order shall state that the enteral, infant and baby 54 formula is clearly medically necessary and has been proven effective as 55 a disease-specific treatment regimen. Specific diseases and disorders 56 for which enteral, infant and baby formulas have been proven effectiveA. 5053 3 1 shall include, but are not limited to, inherited diseases of amino-acid 2 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux; 3 disorders of gastrointestinal motility such as chronic intestinal pseu- 4 do-obstruction; and multiple, severe food allergies including, but not 5 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies 6 to multiple food proteins; severe food protein induced enterocolitis 7 syndrome; eosinophilic disorders; and impaired absorption of nutrients 8 caused by disorders affecting the absorptive surface, function, length, 9 and motility of the gastrointestinal tract. Enteral, infant and baby 10 formulas which are medically necessary and taken under written order 11 from a physician for the treatment of specific diseases shall be distin- 12 guished from nutritional supplements taken electively. Coverage for 13 certain inherited diseases of amino acid and organic acid metabolism as 14 well as severe protein allergic conditions shall include modified solid 15 food products that are low protein, or which contain modified protein, 16 or are amino acid based which are medically necessary, and such coverage 17 for such modified solid food products for any calendar year or for any 18 continuous period of twelve months for any insured individual shall not 19 exceed two thousand five hundred dollars. Coverage for infant and baby 20 formulas for any calendar year or any continuous period of twelve months 21 for any insured individual shall be no less than three thousand dollars. 22 § 4. The opening paragraph of paragraph 25 of subsection (b) of 23 section 4322 of the insurance law, as amended by chapter 388 of the laws 24 of 2013, is amended to read as follows: 25 Prescription drugs, obtained at a participating pharmacy under a 26 prescription written by an in-plan or out-of-plan provider, including 27 contraceptive drugs or devices approved by the federal food and drug 28 administration or generic equivalents approved as substitutes by such 29 food and drug administration [and], nutritional supplements (formulas), 30 whether administered orally or via a feeding tube for the therapeutic 31 treatment of phenylketonuria, branched-chain ketonuria, galactosemia and 32 homocystinuria[, obtained at a participating pharmacy under a33prescription written by an in-plan or out-of-plan provider] and infant 34 and baby formulas for home use for which a physician or other licensed 35 health care provider legally authorized to prescribe under title eight 36 of the education law has issued a written order. Such written order 37 shall state that the infant or baby formula is clearly medically neces- 38 sary and has been proven effective as a disease-specific treatment regi- 39 men for those individuals who are or will become malnourished or suffer 40 from disorders, which if left untreated, cause chronic physical disabil- 41 ity, mental retardation or death. Specific diseases for which infant and 42 baby formulas have been proven effective shall include, but are not 43 limited to, inherited diseases of amino acid or organic acid metabolism; 44 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor- 45 ders of gastrointestinal motility such as chronic intestinal pseudo-ob- 46 struction; and multiple, severe food allergies which if left untreated 47 will cause malnourishment, chronic physical disability, mental retarda- 48 tion or death. Infant and baby formulas which are medically necessary 49 and taken under written order from a physician for the treatment of 50 specific diseases shall be distinguished from nutritional supplements 51 taken electively. Coverage for infant and baby formulas for any calendar 52 year or any continuous period of twelve months for any insured individ- 53 ual shall be no less than three thousand dollars. Health maintenance 54 organizations, in addition to providing coverage for prescription drugs 55 at a participating pharmacy, may utilize a mail order prescription drug 56 program. Health maintenance organizations may provide prescription drugsA. 5053 4 1 pursuant to a drug formulary; however, health maintenance organizations 2 must implement an appeals process so that the use of non-formulary 3 prescription drugs may be requested by a physician or other provider. 4 § 5. This act shall take effect on the first of January next succeed- 5 ing the date on which it shall have become a law and shall apply to all 6 policies and contracts issued, renewed, modified, altered, or amended on 7 or after such date.
