Bill Text: NY S02043 | 2015-2016 | 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) 2016-01-06 - REFERRED TO INSURANCE [S02043 Detail]

Download: New_York-2015-S02043-Introduced.html
                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                         2043
                              2015-2016 Regular Sessions
                                   I N  S E N A T E
                                   January 21, 2015
                                      ___________
       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 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, 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 for those individuals  who  are  or
   12  will  become  malnourished  or  suffer  from  disorders,  which  if left
   13  untreated, cause chronic  physical  disability,  mental  retardation  or
   14  death.  Specific  diseases  for  which enteral, INFANT AND BABY formulas
   15  have been proven effective shall include, but are not limited to, inher-
   16  ited diseases of amino acid or organic acid metabolism; Crohn's Disease;
   17  gastroesophageal reflux with failure to thrive; disorders  of  gastroin-
   18  testinal  motility  such  as  chronic intestinal pseudo-obstruction; and
   19  multiple, severe food allergies which if left untreated will cause maln-
   20  ourishment, chronic physical disability, mental  retardation  or  death.
   21  Enteral,  INFANT  AND  BABY  formulas  which are medically necessary and
   22  taken under written order from a physician for the treatment of specific
   23  diseases shall be distinguished from nutritional supplements taken elec-
   24  tively. Coverage for certain inherited diseases of amino acid and organ-
   25  ic acid metabolism shall include modified solid food products  that  are
   26  low protein or which contain modified protein which are medically neces-
   27  sary,  and  such  coverage for such modified solid food products for any
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD06715-01-5
       S. 2043                             2
    1  calendar year or for any continuous period  of  twelve  months  for  any
    2  insured  individual  shall not exceed two thousand five hundred dollars.
    3  COVERAGE FOR INFANT AND BABY FORMULAS  FOR  ANY  CALENDAR  YEAR  OR  ANY
    4  CONTINUOUS  PERIOD  OF TWELVE MONTHS FOR ANY INSURED INDIVIDUAL SHALL BE
    5  NO LESS THAN THREE THOUSAND DOLLARS.
    6    S 2. Paragraph 11 of subsection (k) of section 3221 of  the  insurance
    7  law,  as  amended by chapter 388 of the laws of 2013, is amended to read
    8  as follows:
    9    (11) Every policy which provides coverage for prescription drugs shall
   10  include coverage for the cost of enteral, INFANT AND BABY  formulas  for
   11  home  use,  whether administered orally or via tube feeding, for which a
   12  physician or other licensed health care provider legally  authorized  to
   13  prescribe  under  title  eight of the education law has issued a written
   14  order. Such written order shall state that the enteral, INFANT AND  BABY
   15  formula  is clearly medically necessary and has been proven effective as
   16  a disease-specific treatment regimen for those individuals  who  are  or
   17  will  become  malnourished  or  suffer  from  disorders,  which  if left
   18  untreated, cause chronic  physical  disability,  mental  retardation  or
   19  death.  Specific  diseases  for  which enteral, INFANT AND BABY formulas
   20  have been proven effective shall include, but are not limited to, inher-
   21  ited diseases of amino-acid or organic acid metabolism; Crohn's Disease;
   22  gastroesophageal reflux with failure to thrive; disorders  of  gastroin-
   23  testinal  motility  such  as  chronic intestinal pseudo-obstruction; and
   24  multiple, severe food allergies which if left untreated will cause maln-
   25  ourishment, chronic physical disability, mental  retardation  or  death.
   26  Enteral,  INFANT  AND  BABY  formulas  which are medically necessary and
   27  taken under written order from a physician for the treatment of specific
   28  diseases shall be distinguished from nutritional supplements taken elec-
   29  tively. Coverage for certain inherited diseases of amino acid and organ-
   30  ic acid metabolism shall include modified solid food products  that  are
   31  low protein or which contain modified protein which are medically neces-
   32  sary,  and  such  coverage for such modified solid food products for any
   33  calendar year or for any continuous period  of  twelve  months  for  any
   34  insured  individual  shall not exceed two thousand five hundred dollars.
   35  COVERAGE FOR INFANT AND BABY FORMULAS  FOR  ANY  CALENDAR  YEAR  OR  ANY
   36  CONTINUOUS  PERIOD  OF TWELVE MONTHS FOR ANY INSURED INDIVIDUAL SHALL BE
   37  NO LESS THAN THREE THOUSAND DOLLARS.
   38    S 3. Subsection (y) of section 4303 of the insurance law,  as  amended
   39  by chapter 388 of the laws of 2013, is amended to read as follows:
   40    (y)  Every  contract  which  provides  coverage for prescription drugs
   41  shall include coverage for the cost of enteral, INFANT AND BABY formulas
   42  for home use, whether administered orally or via tube feeding, for which
   43  a physician or other licensed health care provider legally authorized to
   44  prescribe under title eight of the education law has  issued  a  written
   45  order.  Such written order shall state that the enteral, INFANT AND BABY
   46  formula is clearly medically necessary and has been proven effective  as
   47  a  disease-specific  treatment  regimen for those individuals who are or
   48  will become  malnourished  or  suffer  from  disorders,  which  if  left
   49  untreated,  cause  chronic  disability,  mental  retardation  or  death.
   50  Specific diseases for which enteral, INFANT AND BABY formulas have  been
   51  proven  effective  shall  include,  but  are  not  limited to, inherited
   52  diseases of amino-acid or  organic  acid  metabolism;  Crohn's  Disease;
   53  gastroesophageal  reflux  with failure to thrive; disorders of gastroin-
   54  testinal motility such as  chronic  intestinal  pseudo-obstruction;  and
   55  multiple, severe food allergies which if left untreated will cause maln-
   56  ourishment,  chronic  physical  disability, mental retardation or death.
       S. 2043                             3
    1  Enteral, INFANT AND BABY formulas  which  are  medically  necessary  and
    2  taken under written order from a physician for the treatment of specific
    3  diseases shall be distinguished from nutritional supplements taken elec-
    4  tively. Coverage for certain inherited diseases of amino acid and organ-
    5  ic  acid  metabolism shall include modified solid food products that are
    6  low protein, or which  contain  modified  protein  which  are  medically
    7  necessary,  and  such coverage for such modified solid food products for
    8  any calendar year or for any continuous period of twelve months for  any
    9  insured  individual  shall not exceed two thousand five hundred dollars.
   10  COVERAGE FOR INFANT AND BABY FORMULAS  FOR  ANY  CALENDAR  YEAR  OR  ANY
   11  CONTINUOUS  PERIOD  OF TWELVE MONTHS FOR ANY INSURED INDIVIDUAL SHALL BE
   12  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 388 of the laws
   15  of 2013, 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  whether administered orally or via a feeding tube  for  the  therapeutic
   22  treatment of phenylketonuria, branched-chain ketonuria, galactosemia and
   23  homocystinuria[,   obtained   at   a   participating  pharmacy  under  a
   24  prescription written by an in-plan or out-of-plan provider]  AND  INFANT
   25  AND  BABY  FORMULAS FOR HOME USE FOR WHICH A PHYSICIAN OR OTHER LICENSED
   26  HEALTH CARE PROVIDER LEGALLY AUTHORIZED TO PRESCRIBE UNDER  TITLE  EIGHT
   27  OF  THE  EDUCATION  LAW  HAS  ISSUED A WRITTEN ORDER. SUCH WRITTEN ORDER
   28  SHALL STATE THAT THE INFANT OR BABY FORMULA IS CLEARLY MEDICALLY  NECES-
   29  SARY AND HAS BEEN PROVEN EFFECTIVE AS A DISEASE-SPECIFIC TREATMENT REGI-
   30  MEN  FOR THOSE INDIVIDUALS WHO ARE OR WILL BECOME MALNOURISHED OR SUFFER
   31  FROM DISORDERS, WHICH IF LEFT UNTREATED, CAUSE CHRONIC PHYSICAL DISABIL-
   32  ITY, MENTAL RETARDATION OR DEATH. SPECIFIC DISEASES FOR WHICH INFANT AND
   33  BABY FORMULAS HAVE BEEN PROVEN EFFECTIVE  SHALL  INCLUDE,  BUT  ARE  NOT
   34  LIMITED TO, INHERITED DISEASES OF AMINO ACID OR ORGANIC ACID METABOLISM;
   35  CROHN'S  DISEASE; GASTROESOPHAGEAL REFLUX WITH FAILURE TO THRIVE; DISOR-
   36  DERS OF GASTROINTESTINAL MOTILITY SUCH AS CHRONIC INTESTINAL  PSEUDO-OB-
   37  STRUCTION;  AND  MULTIPLE, SEVERE FOOD ALLERGIES WHICH IF LEFT UNTREATED
   38  WILL CAUSE MALNOURISHMENT, CHRONIC PHYSICAL DISABILITY, MENTAL  RETARDA-
   39  TION  OR  DEATH.  INFANT AND BABY FORMULAS WHICH ARE MEDICALLY NECESSARY
   40  AND TAKEN UNDER WRITTEN ORDER FROM A  PHYSICIAN  FOR  THE  TREATMENT  OF
   41  SPECIFIC  DISEASES  SHALL  BE DISTINGUISHED FROM NUTRITIONAL SUPPLEMENTS
   42  TAKEN ELECTIVELY. COVERAGE FOR INFANT AND BABY FORMULAS FOR ANY CALENDAR
   43  YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR ANY INSURED  INDIVID-
   44  UAL  SHALL  BE  NO LESS THAN THREE THOUSAND DOLLARS.  Health maintenance
   45  organizations, in addition to providing coverage for prescription  drugs
   46  at  a participating pharmacy, may utilize a mail order prescription drug
   47  program. Health maintenance organizations may provide prescription drugs
   48  pursuant to a drug formulary; however, health maintenance  organizations
   49  must  implement  an  appeals  process  so  that the use of non-formulary
   50  prescription drugs may be requested by a physician or 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.
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