Enacts "Hannah's law"; requires that every health insurance policy or contract which provides coverage for prescription drugs include coverage for the cost of enteral formulas administered orally or via feeding tube.
STATE OF NEW YORK
________________________________________________________________________
490--A
2013-2014 Regular Sessions
IN ASSEMBLY(Prefiled)
January 9, 2013
___________
Introduced by M. of A. PAULIN, GUNTHER, MAISEL, ZEBROWSKI, KATZ, ROSEN-
THAL, HOOPER -- Multi-Sponsored by -- M. of A. CERETTO, DINOWITZ --
read once and referred to the Committee on Insurance -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee
AN ACT to amend the insurance law, in relation to requiring certain
health insurance policies to include coverage for the cost of enteral
formulas whether administered orally or via tube feeding
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Short title. This act shall be known and may be cited as
2 "Hannah's law".
3 § 2. Paragraph 21 of subsection (i) of section 3216 of the insurance
4 law, as added by chapter 177 of the laws of 1997, is amended to read as
5 follows:
6 (21) Every policy which provides coverage for prescription drugs shall
7 include coverage for the cost of enteral formulas for home use, whether
8 administered orally or via tube feeding, for which a physician or other
9 licensed health care provider legally authorized to prescribe under
10 title eight of the education law has issued a written order. Such writ-
11 ten order shall state that the enteral formula is clearly medically
12 necessary and has been proven effective as a disease-specific treatment
13 regimen for those individuals who are or will become malnourished or
14 suffer from disorders, which if left untreated, cause chronic physical
15 disability, mental retardation or death. Specific diseases for which
16 enteral formulas have been proven effective shall include, but are not
17 limited to, inherited diseases of amino acid or organic acid metabolism;
18 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor-
19 ders of gastrointestinal motility such as chronic intestinal pseudo-ob-
20 struction; and multiple, severe food allergies which if left untreated
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD05057-02-3
A. 490--A 2
1 will cause malnourishment, chronic physical disability, mental retarda-
2 tion or death. Enteral formulas which are medically necessary and taken
3 under written order from a physician for the treatment of specific
4 diseases shall be distinguished from nutritional supplements taken elec-
5 tively. Coverage for certain inherited diseases of amino acid and organ-
6 ic acid metabolism shall include modified solid food products that are
7 low protein or which contain modified protein which are medically neces-
8 sary, and such coverage for such modified solid food products for any
9 calendar year or for any continuous period of twelve months for any
10 insured individual shall not exceed two thousand five hundred dollars.
11 § 3. Paragraph 11 of subsection (k) of section 3221 of the insurance
12 law, as added by chapter 177 of the laws of 1997, is amended to read as
13 follows:
14 (11) Every policy which provides coverage for prescription drugs shall
15 include coverage for the cost of enteral formulas for home use, whether
16 administered orally or via tube feeding, for which a physician or other
17 licensed health care provider legally authorized to prescribe under
18 title eight of the education law has issued a written order. Such writ-
19 ten order shall state that the enteral formula is clearly medically
20 necessary and has been proven effective as a disease-specific treatment
21 regimen for those individuals who are or will become malnourished or
22 suffer from disorders, which if left untreated, cause chronic physical
23 disability, mental retardation or death. Specific diseases for which
24 enteral formulas have been proven effective shall include, but are not
25 limited to, inherited diseases of amino-acid or organic acid metabolism;
26 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor-
27 ders of gastrointestinal motility such as chronic intestinal pseudo-ob-
28 struction; and multiple, severe food allergies which if left untreated
29 will cause malnourishment, chronic physical disability, mental retarda-
30 tion or death. Enteral formulas which are medically necessary and taken
31 under written order from a physician for the treatment of specific
32 diseases shall be distinguished from nutritional supplements taken elec-
33 tively. Coverage for certain inherited diseases of amino acid and organ-
34 ic acid metabolism shall include modified solid food products that are
35 low protein or which contain modified protein which are medically neces-
36 sary, and such coverage for such modified solid food products for any
37 calendar year or for any continuous period of twelve months for any
38 insured individual shall not exceed two thousand five hundred dollars.
39 § 4. 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 formulas for home use,
43 whether administered orally or via tube feeding, for which a physician
44 or other licensed health care provider legally authorized to prescribe
45 under title eight of the education law has issued a written order. Such
46 written order shall state that the enteral formula is clearly medically
47 necessary and has been proven effective as a disease-specific treatment
48 regimen for those individuals who are or will become malnourished or
49 suffer from disorders, which if left untreated, cause chronic disabili-
50 ty, mental retardation or death. Specific diseases for which enteral
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
A. 490--A 3
1 death. Enteral formulas which are medically necessary and taken under
2 written order from a physician for the treatment of specific diseases
3 shall be distinguished from nutritional supplements taken electively.
4 Coverage for certain inherited diseases of amino acid and organic acid
5 metabolism shall include modified solid food products that are low
6 protein, or which contain modified protein which are medically neces-
7 sary, and such coverage for such modified solid food products for any
8 calendar year or for any continuous period of twelve months for any
9 insured individual shall not exceed two thousand five hundred dollars.
10 § 5. The opening paragraph of paragraph 25 of subsection (b) of
11 section 4322 of the insurance law, as amended by chapter 554 of the laws
12 of 2002, is amended to read as follows:
13 Prescription drugs, including contraceptive drugs or devices approved
14 by the federal food and drug administration or generic equivalents
15 approved as substitutes by such food and drug administration and nutri-
16 tional supplements (formulas), whether administered orally or via a
17 feeding tube for the therapeutic treatment of phenylketonuria, branched-
18 chain ketonuria, galactosemia and homocystinuria, obtained at a partic-
19 ipating pharmacy under a prescription written by an in-plan or out-of-
20 plan provider. Health maintenance organizations, in addition to
21 providing coverage for prescription drugs at a participating pharmacy,
22 may utilize a mail order prescription drug program. Health maintenance
23 organizations may provide prescription drugs pursuant to a drug formu-
24 lary; however, health maintenance organizations must implement an
25 appeals process so that the use of non-formulary prescription drugs may
26 be requested by a physician or other provider.
27 § 6. This act shall take effect on the first of January next succeed-
28 ing the date on which it shall have become a law and shall apply to all
29 policies and contracts issued, renewed, modified, altered, or amended on
30 or after such date.
