STATE OF NEW YORK
________________________________________________________________________
868
2025-2026 Regular Sessions
IN SENATE(Prefiled)
January 8, 2025
___________
Introduced by Sen. BAILEY -- 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 section 6 of subpart B of part J of chapter
3 57 of the laws of 2019, is amended to read as follows:
4 (21) Every policy that 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
22 formulas that are medically necessary and taken under written order from
23 a physician for the treatment of specific diseases shall be distin-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD02111-01-5
S. 868 2
1 guished from nutritional supplements taken electively. Coverage for
2 certain inherited diseases of amino acid and organic acid metabolism as
3 well as severe protein allergic conditions shall include modified solid
4 food products that are low protein, contain modified protein, or are
5 amino acid based that are medically necessary. Coverage for infant and
6 baby formulas for any calendar year or any continuous period of twelve
7 months for any insured individual shall be no less than three thousand
8 dollars.
9 § 2. Paragraph 11 of subsection (k) of section 3221 of the insurance
10 law, as amended by section 14 of subpart B of part J of chapter 57 of
11 the laws of 2019, is amended to read as follows:
12 (11) Every policy that provides coverage for prescription drugs shall
13 include coverage for the cost of enteral, infant and baby formulas for
14 home use, whether administered orally or via tube feeding, for which a
15 physician or other licensed health care provider legally authorized to
16 prescribe under title eight of the education law has issued a written
17 order. Such written order shall state that the enteral, infant and baby
18 formula is clearly medically necessary and has been proven effective as
19 a disease-specific treatment regimen. Specific diseases and disorders
20 for which enteral, infant and baby formulas have been proven effective
21 shall include, but are not limited to, inherited diseases of amino-acid
22 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux;
23 disorders of gastrointestinal motility such as chronic intestinal pseu-
24 do-obstruction; and multiple, severe food allergies including, but not
25 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies
26 to multiple food proteins; severe food protein induced enterocolitis
27 syndrome; eosinophilic disorders and impaired absorption of nutrients
28 caused by disorders affecting the absorptive surface, function, length,
29 and motility of the gastrointestinal tract. Enteral, infant and baby
30 formulas that are medically necessary and taken under written order from
31 a physician for the treatment of specific diseases shall be distin-
32 guished from nutritional supplements taken electively. Coverage for
33 certain inherited diseases of amino acid and organic acid metabolism as
34 well as severe protein allergic conditions shall include modified solid
35 food products that are low protein, contain modified protein, or are
36 amino acid based that are medically necessary. Coverage for infant and
37 baby formulas for any calendar year or any continuous period of twelve
38 months for any insured individual shall be no less than three thousand
39 dollars.
40 § 3. Subsection (y) of section 4303 of the insurance law, as amended
41 by section 27 of subpart B of part J of chapter 57 of the laws of 2019,
42 is amended to read as follows:
43 (y) Every contract that provides coverage for prescription drugs shall
44 include coverage for the cost of enteral, infant and baby formulas for
45 home use, whether administered orally or via tube feeding, for which a
46 physician or other licensed health care provider legally authorized to
47 prescribe under title eight of the education law has issued a written
48 order. Such written order shall state that the enteral, infant and baby
49 formula is clearly medically necessary and has been proven effective as
50 a disease-specific treatment regimen. Specific diseases and disorders
51 for which enteral, infant and baby formulas have been proven effective
52 shall include, but are not limited to, inherited diseases of amino-acid
53 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux;
54 disorders of gastrointestinal motility such as chronic intestinal pseu-
55 do-obstruction; and multiple, severe food allergies including, but not
56 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies
S. 868 3
1 to multiple food proteins; severe food protein induced enterocolitis
2 syndrome; eosinophilic disorders; and impaired absorption of nutrients
3 caused by disorders affecting the absorptive surface, function, length,
4 and motility of the gastrointestinal tract. Enteral, infant and baby
5 formulas that are medically necessary and taken under written order from
6 a physician for the treatment of specific diseases shall be distin-
7 guished from nutritional supplements taken electively. Coverage for
8 certain inherited diseases of amino acid and organic acid metabolism as
9 well as severe protein allergic conditions shall include modified solid
10 food products that are low protein, contain modified protein, or are
11 amino acid based that are medically necessary. Coverage for infant and
12 baby formulas for any calendar year or any continuous period of twelve
13 months for any insured individual shall be no less than three thousand
14 dollars.
15 § 4. The opening paragraph of paragraph 25 of subsection (b) of
16 section 4322 of the insurance law, as amended by chapter 388 of the laws
17 of 2013, is amended to read as follows:
18 Prescription drugs, obtained at a participating pharmacy under a
19 prescription written by an in-plan or out-of-plan provider, including
20 contraceptive drugs or devices approved by the federal food and drug
21 administration or generic equivalents approved as substitutes by such
22 food and drug administration [and], nutritional supplements (formulas),
23 whether administered orally or via a feeding tube for the therapeutic
24 treatment of phenylketonuria, branched-chain ketonuria, galactosemia and
25 homocystinuria[, obtained at a participating pharmacy under a
26 prescription written by an in-plan or out-of-plan provider] and infant
27 and baby formulas for home use for which a physician or other licensed
28 health care provider legally authorized to prescribe under title eight
29 of the education law has issued a written order. Such written order
30 shall state that the infant or baby formula is clearly medically neces-
31 sary and has been proven effective as a disease-specific treatment regi-
32 men for those individuals who are or will become malnourished or suffer
33 from disorders, which if left untreated, cause chronic physical disabil-
34 ity, mental retardation or death. Specific diseases for which infant and
35 baby formulas have been proven effective shall include, but are not
36 limited to, inherited diseases of amino acid or organic acid metabolism;
37 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor-
38 ders of gastrointestinal motility such as chronic intestinal pseudo-ob-
39 struction; and multiple, severe food allergies which if left untreated
40 will cause malnourishment, chronic physical disability, mental retarda-
41 tion or death. Infant and baby formulas which are medically necessary
42 and taken under written order from a physician for the treatment of
43 specific diseases shall be distinguished from nutritional supplements
44 taken electively. Coverage for infant and baby formulas for any calendar
45 year or any continuous period of twelve months for any insured individ-
46 ual shall be no less than three thousand dollars. Health maintenance
47 organizations, in addition to providing coverage for prescription drugs
48 at a participating pharmacy, may utilize a mail order prescription drug
49 program. Health maintenance organizations may provide prescription drugs
50 pursuant to a drug formulary; however, health maintenance organizations
51 must implement an appeals process so that the use of non-formulary
52 prescription drugs may be requested by a physician or other provider.
53 § 5. This act shall take effect on the first of January next succeed-
54 ing the date on which it shall have become a law and shall apply to all
55 policies and contracts issued, renewed, modified, altered, or amended on
56 or after such date.
