STATE OF NEW YORK
________________________________________________________________________
11043
IN ASSEMBLY
May 31, 2018
___________
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Stern) --
read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to insurance coverage for
enteral formula
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 388 of the laws of 2013, 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 formulas for home use, whether
6 administered orally or via tube feeding, for which a physician or other
7 licensed health care provider legally authorized to prescribe under
8 title eight of the education law has issued a written order. Such writ-
9 ten order shall state that the enteral formula is clearly medically
10 necessary and has been proven effective as a disease-specific treatment
11 regimen [for those individuals who are or will become malnourished or
12 suffer from disorders, which if left untreated, cause chronic physical
13 disability, mental retardation or death]. Specific diseases and disor-
14 ders for which enteral formulas have been proven effective shall
15 include, but are not limited to, inherited diseases of amino acid or
16 organic acid metabolism; Crohn's Disease; gastroesophageal reflux [with
17 failure to thrive]; disorders of gastrointestinal motility such as
18 chronic intestinal pseudo-obstruction; and multiple, severe food aller-
19 gies [which if left untreated will cause malnourishment, chronic phys-
20 ical disability, mental retardation or death] including, but not limited
21 to immunoglobulin E and nonimmunoglobulin E-mediated allergies to multi-
22 ple food proteins; severe food protein induced enterocolitis syndrome;
23 eosinophilic disorders; and impaired absorption of nutrients caused by
24 disorders affecting the absorptive surface, function, length, and motil-
25 ity of the gastrointestinal tract. Enteral formulas which are medically
26 necessary and taken under written order from a physician for the treat-
27 ment of specific diseases shall be distinguished from nutritional
28 supplements taken electively. Coverage for certain inherited diseases of
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD16153-01-8
A. 11043 2
1 amino acid and organic acid metabolism as well as severe protein aller-
2 gic conditions shall include modified solid food products that are low
3 protein or which contain modified protein, or are amino acid based which
4 are medically necessary, and such coverage for such modified solid food
5 products for any calendar year or for any continuous period of twelve
6 months for any insured individual shall not exceed two thousand five
7 hundred dollars.
8 § 2. Paragraph 11 of subsection (k) of section 3221 of the insurance
9 law, as amended by chapter 388 of the laws of 2013, is amended to read
10 as follows:
11 (11) Every policy which provides coverage for prescription drugs shall
12 include coverage for the cost of enteral formulas for home use, whether
13 administered orally or via tube feeding, for which a physician or other
14 licensed health care provider legally authorized to prescribe under
15 title eight of the education law has issued a written order. Such writ-
16 ten order shall state that the enteral formula is clearly medically
17 necessary and has been proven effective as a disease-specific treatment
18 regimen [for those individuals who are or will become malnourished or
19 suffer from disorders, which if left untreated, cause chronic physical
20 disability, mental retardation or death]. Specific diseases and disor-
21 ders for which enteral formulas have been proven effective shall
22 include, but are not limited to, inherited diseases of amino-acid or
23 organic acid metabolism; Crohn's Disease; gastroesophageal reflux [with
24 failure to thrive]; disorders of gastrointestinal motility such as
25 chronic intestinal pseudo-obstruction; and multiple, severe food aller-
26 gies [which if left untreated will cause malnourishment, chronic phys-
27 ical disability, mental retardation or death] including, but not limited
28 to immunoglobulin E and nonimmunoglobulin E-mediated allergies to multi-
29 ple food proteins; severe food protein induced enterocolitis syndrome;
30 eosinophilic disorders and impaired absorption of nutrients caused by
31 disorders affecting the absorptive surface, function, length, and motil-
32 ity of the gastrointestinal tract. Enteral formulas which are medically
33 necessary and taken under written order from a physician for the treat-
34 ment of specific diseases shall be distinguished from nutritional
35 supplements taken electively. Coverage for certain inherited diseases of
36 amino acid and organic acid metabolism as well as severe protein aller-
37 gic conditions shall include modified solid food products that are low
38 protein or which contain modified protein, or are amino acid based which
39 are medically necessary, and such coverage for such modified solid food
40 products for any calendar year or for any continuous period of twelve
41 months for any insured individual shall not exceed two thousand five
42 hundred dollars.
43 § 3. Subsection (y) of section 4303 of the insurance law, as amended
44 by chapter 388 of the laws of 2013, is amended to read as follows:
45 (y) Every contract which provides coverage for prescription drugs
46 shall include coverage for the cost of enteral formulas for home use,
47 whether administered orally or via tube feeding, for which a physician
48 or other licensed health care provider legally authorized to prescribe
49 under title eight of the education law has issued a written order. Such
50 written order shall state that the enteral formula is clearly medically
51 necessary and has been proven effective as a disease-specific treatment
52 regimen [for those individuals who are or will become malnourished or
53 suffer from disorders, which if left untreated, cause chronic disabili-
54 ty, mental retardation or death]. Specific diseases and disorders for
55 which enteral formulas have been proven effective shall include, but are
56 not limited to, inherited diseases of amino-acid or organic acid meta-
A. 11043 3
1 bolism; Crohn's Disease; gastroesophageal reflux [with failure to
2 thrive]; disorders of gastrointestinal motility such as chronic intesti-
3 nal pseudo-obstruction; and multiple, severe food allergies [which if
4 left untreated will cause malnourishment, chronic physical disability,
5 mental retardation or death] including, but not limited to immunoglobu-
6 lin E and nonimmunoglobulin E-mediated allergies to multiple food prote-
7 ins; severe food protein induced enterocolitis syndrome; eosinophilic
8 disorders; and impaired absorption of nutrients caused by disorders
9 affecting the absorptive surface, function, length, and motility of the
10 gastrointestinal tract. Enteral formulas which are medically necessary
11 and taken under written order from a physician for the treatment of
12 specific diseases shall be distinguished from nutritional supplements
13 taken electively. Coverage for certain inherited diseases of amino acid
14 and organic acid metabolism as well as severe protein allergic condi-
15 tions shall include modified solid food products that are low protein,
16 or which contain modified protein, or are amino acid based which are
17 medically necessary, and such coverage for such modified solid food
18 products for any calendar year or for any continuous period of twelve
19 months for any insured individual shall not exceed two thousand five
20 hundred dollars.
21 § 4. This act shall take effect on the first of January next succeed-
22 ing the date on which it shall have become a law and shall apply to all
23 policies and contracts issued, renewed, modified, altered, or amended on
24 or after such date.