Bill Text: NY A11043 | 2017-2018 | General Assembly | Introduced

---

Bill Title: Relates to insurance coverage for enteral formula; includes additional diseases and disorders for which enteral formula has been proven effective.

Spectrum: Bipartisan Bill

Status: (Passed) 2018-12-28 - signed chap.469 [A11043 Detail]

Download: New_York-2017-A11043-Introduced.html

---

                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.