Bill Text: NY S03270 | 2011-2012 | General Assembly | Introduced
Bill Title: Requires certain health insurance policies to include coverage for the cost of certain infant and baby formulas.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2012-03-12 - COMMITTEE DISCHARGED AND COMMITTED TO RULES [S03270 Detail]
Download: New_York-2011-S03270-Introduced.html
S T A T E O F N E W Y O R K ________________________________________________________________________ 3270 2011-2012 Regular Sessions I N S E N A T E February 15, 2011 ___________ Introduced by Sen. HASSELL-THOMPSON -- read twice and ordered printed, and when printed to be committed 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 added by chapter 177 of the laws of 1997, 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 for which a physician or other licensed health care provider 7 legally authorized to prescribe under title eight of the education law 8 has issued a written order. Such written order shall state that the 9 enteral, INFANT OR BABY formula is clearly medically necessary and has 10 been proven effective as a disease-specific treatment regimen for those 11 individuals who are or will become malnourished or suffer from disor- 12 ders, which if left untreated, cause chronic physical disability, mental 13 retardation or death. Specific diseases for which enteral, INFANT AND 14 BABY formulas have been proven effective shall include, but are not 15 limited to, inherited diseases of amino acid or organic acid metabolism; 16 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor- 17 ders of gastrointestinal motility such as chronic intestinal pseudo-ob- 18 struction; and multiple, severe food allergies which if left untreated 19 will cause malnourishment, chronic physical disability, mental retarda- 20 tion or death. Enteral, INFANT AND BABY formulas which are medically 21 necessary and taken under written order from a physician for the treat- 22 ment of specific diseases shall be distinguished from nutritional 23 supplements taken electively. Coverage for certain inherited diseases of 24 amino acid and organic acid metabolism shall include modified solid food EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD07103-01-1 S. 3270 2 1 products that are low protein or which contain modified protein which 2 are medically necessary, and such coverage for such modified solid food 3 products for any calendar year or for any continuous period of twelve 4 months for any insured individual shall not exceed two thousand five 5 hundred dollars. COVERAGE FOR INFANT AND BABY FORMULAS FOR ANY CALENDAR 6 YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR ANY INSURED INDIVID- 7 UAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS. 8 S 2. Paragraph 11 of subsection (k) of section 3221 of the insurance 9 law, as added by chapter 177 of the laws of 1997, is amended to read as 10 follows: 11 (11) Every policy which provides coverage for prescription drugs shall 12 include coverage for the cost of enteral, INFANT AND BABY formulas for 13 home use for which a physician or other licensed health care provider 14 legally authorized to prescribe under title eight of the education law 15 has issued a written order. Such written order shall state that the 16 enteral, INFANT OR BABY formula is clearly medically necessary and has 17 been proven effective as a disease-specific treatment regimen for those 18 individuals who are or will become malnourished or suffer from disor- 19 ders, which if left untreated, cause chronic physical disability, mental 20 retardation or death. Specific diseases for which enteral, INFANT AND 21 BABY formulas have been proven effective shall include, but are not 22 limited to, inherited diseases of amino-acid or organic acid metabolism; 23 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor- 24 ders of gastrointestinal motility such as chronic intestinal pseudo-ob- 25 struction; and multiple, severe food allergies which if left untreated 26 will cause malnourishment, chronic physical disability, mental retarda- 27 tion or death. Enteral, INFANT AND BABY formulas which are medically 28 necessary and taken under written order from a physician for the treat- 29 ment of specific diseases shall be distinguished from nutritional 30 supplements taken electively. Coverage for certain inherited diseases of 31 amino acid and organic acid metabolism shall include modified solid food 32 products that are low protein or which contain modified protein which 33 are medically necessary, and such coverage for such modified solid food 34 products for any calendar year or for any continuous period of twelve 35 months for any insured individual shall not exceed two thousand five 36 hundred dollars. COVERAGE FOR INFANT AND BABY FORMULAS FOR ANY CALENDAR 37 YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR ANY INSURED INDIVID- 38 UAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS. 39 S 3. Subsection (y) of section 4303 of the insurance law, as added by 40 chapter 177 of the laws of 1997, is amended to read as follows: 41 (y) Every contract which provides coverage for prescription drugs 42 shall include coverage for the cost of enteral, INFANT AND BABY formulas 43 for home use for which a physician or other licensed health care provid- 44 er legally authorized to prescribe under title eight of the education 45 law has issued a written order. Such written order shall state that the 46 enteral, INFANT OR BABY formula is clearly medically necessary and has 47 been proven effective as a disease-specific treatment regimen for those 48 individuals who are or will become malnourished or suffer from disor- 49 ders, which if left untreated, cause chronic disability, mental retarda- 50 tion or death. Specific diseases for which enteral, INFANT AND BABY 51 formulas have been proven effective shall include, but are not limited 52 to, inherited diseases of amino-acid or organic acid metabolism; Crohn's 53 Disease; gastroesophageal reflux with failure to thrive; disorders of 54 gastrointestinal motility such as chronic intestinal pseudo-obstruction; 55 and multiple, severe food allergies which if left untreated will cause 56 malnourishment, chronic physical disability, mental retardation or S. 3270 3 1 death. Enteral, INFANT AND BABY formulas which are medically necessary 2 and taken under written order from a physician for the treatment of 3 specific diseases shall be distinguished from nutritional supplements 4 taken electively. Coverage for certain inherited diseases of amino acid 5 and organic acid metabolism shall include modified solid food products 6 that are low protein, or which contain modified protein which are 7 medically necessary, and such coverage for such modified solid food 8 products for any calendar year or for any continuous period of twelve 9 months for any insured individual shall not exceed two thousand five 10 hundred dollars. COVERAGE FOR INFANT AND BABY FORMULAS FOR ANY CALENDAR 11 YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR ANY INSURED INDIVID- 12 UAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS. 13 S 4. The opening paragraph of paragraph 25 of subsection (b) of 14 section 4322 of the insurance law, as amended by chapter 554 of the laws 15 of 2002, is amended to read as follows: 16 Prescription drugs, OBTAINED AT A PARTICIPATING PHARMACY UNDER A 17 PRESCRIPTION WRITTEN BY AN IN-PLAN OR OUT-OF-PLAN PROVIDER, including 18 contraceptive drugs or devices approved by the federal food and drug 19 administration or generic equivalents approved as substitutes by such 20 food and drug administration [and], nutritional supplements (formulas) 21 for the therapeutic treatment of phenylketonuria, branched-chain ketonu- 22 ria, galactosemia and homocystinuria[, obtained at a participating phar- 23 macy under a prescription written by an in-plan or out-of-plan provider] 24 AND INFANT AND BABY FORMULAS FOR HOME USE FOR WHICH A PHYSICIAN OR OTHER 25 LICENSED HEALTH CARE PROVIDER LEGALLY AUTHORIZED TO PRESCRIBE UNDER 26 TITLE EIGHT OF THE EDUCATION LAW HAS ISSUED A WRITTEN ORDER. SUCH WRIT- 27 TEN ORDER SHALL STATE THAT THE INFANT OR BABY FORMULA IS CLEARLY 28 MEDICALLY NECESSARY AND HAS BEEN PROVEN EFFECTIVE AS A DISEASE-SPECIFIC 29 TREATMENT REGIMEN FOR THOSE INDIVIDUALS WHO ARE OR WILL BECOME MALNOUR- 30 ISHED OR SUFFER FROM DISORDERS, WHICH IF LEFT UNTREATED, CAUSE CHRONIC 31 PHYSICAL DISABILITY, MENTAL RETARDATION OR DEATH. SPECIFIC DISEASES FOR 32 WHICH INFANT AND BABY FORMULAS HAVE BEEN PROVEN EFFECTIVE SHALL INCLUDE, 33 BUT ARE NOT LIMITED TO, INHERITED DISEASES OF AMINO ACID OR ORGANIC ACID 34 METABOLISM; CROHN'S DISEASE; GASTROESOPHAGEAL REFLUX WITH FAILURE TO 35 THRIVE; DISORDERS OF GASTROINTESTINAL MOTILITY SUCH AS CHRONIC INTESTI- 36 NAL PSEUDO-OBSTRUCTION; AND MULTIPLE, SEVERE FOOD ALLERGIES WHICH IF 37 LEFT UNTREATED WILL CAUSE MALNOURISHMENT, CHRONIC PHYSICAL DISABILITY, 38 MENTAL RETARDATION OR DEATH. INFANT AND BABY FORMULAS WHICH ARE 39 MEDICALLY NECESSARY AND TAKEN UNDER WRITTEN ORDER FROM A PHYSICIAN FOR 40 THE TREATMENT OF SPECIFIC DISEASES SHALL BE DISTINGUISHED FROM NUTRI- 41 TIONAL SUPPLEMENTS TAKEN ELECTIVELY. COVERAGE FOR INFANT AND BABY FORMU- 42 LAS FOR ANY CALENDAR YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR 43 ANY INSURED INDIVIDUAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS. 44 Health maintenance organizations, in addition to providing coverage for 45 prescription drugs at a participating pharmacy, may utilize a mail order 46 prescription drug program. Health maintenance organizations may provide 47 prescription drugs pursuant to a drug formulary; however, health mainte- 48 nance organizations must implement an appeals process so that the use of 49 non-formulary prescription drugs may be requested by a physician or 50 other provider. 51 S 5. This act shall take effect on the first of January next succeed- 52 ing the date on which it shall have become a law and shall apply to all 53 policies and contracts issued, renewed, modified, altered, or amended on 54 or after such date.