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A04492 Summary:

A04492 Actions:

A04492 Floor Votes:

A04492 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          4492
 
                               2011-2012 Regular Sessions
 
                   IN ASSEMBLY
 
                                    February 3, 2011
                                       ___________
 
        Introduced by M. of A. MENG, AUBRY, ROBINSON, JAFFEE, JEFFRIES, LANCMAN,
          KAVANAGH, J. RIVERA, SCARBOROUGH, WEPRIN, TITUS, GALEF, CASTRO, MAYER-
          SOHN,  ZEBROWSKI  -- Multi-Sponsored by -- M. of A. BARRON, GOTTFRIED,
          HOOPER, JOHNS, LAVINE,  LIFTON,  LUPARDO,  MARKEY,  McENENY,  MILLMAN,
          NOLAN,  PERRY,  PHEFFER,  WEISENBERG  -- read once and referred 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
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD07103-01-1
        A. 4492                             2
 
     1  amino acid and organic acid metabolism shall include modified solid food
     2  products  that  are  low protein or which contain modified protein which
     3  are medically necessary, and such coverage for such modified solid  food

     4  products  for  any  calendar year or for any continuous period of twelve
     5  months for any insured individual shall not  exceed  two  thousand  five
     6  hundred  dollars. Coverage for infant and baby formulas for any calendar
     7  year or any continuous period of twelve months for any insured  individ-
     8  ual shall be no less than three thousand dollars.
     9    §  2.  Paragraph 11 of subsection (k) of section 3221 of the insurance
    10  law, as added by chapter 177 of the laws of 1997, is amended to read  as
    11  follows:
    12    (11) Every policy which provides coverage for prescription drugs shall
    13  include  coverage  for the cost of enteral, infant and baby formulas for
    14  home use for which a physician or other licensed  health  care  provider
    15  legally  authorized  to prescribe under title eight of the education law

    16  has issued a written order. Such written  order  shall  state  that  the
    17  enteral,  infant  or baby formula is clearly medically necessary and has
    18  been proven effective as a disease-specific treatment regimen for  those
    19  individuals  who  are  or will become malnourished or suffer from disor-
    20  ders, which if left untreated, cause chronic physical disability, mental
    21  retardation or death. Specific diseases for which  enteral,  infant  and
    22  baby  formulas  have  been  proven  effective shall include, but are not
    23  limited to, inherited diseases of amino-acid or organic acid metabolism;
    24  Crohn's Disease; gastroesophageal reflux with failure to thrive;  disor-
    25  ders  of gastrointestinal motility such as chronic intestinal pseudo-ob-
    26  struction; and multiple, severe food allergies which if  left  untreated

    27  will  cause malnourishment, chronic physical disability, mental retarda-
    28  tion or death.  Enteral, infant and baby formulas  which  are  medically
    29  necessary  and taken under written order from a physician for the treat-
    30  ment of  specific  diseases  shall  be  distinguished  from  nutritional
    31  supplements taken electively. Coverage for certain inherited diseases of
    32  amino acid and organic acid metabolism shall include modified solid food
    33  products  that  are  low protein or which contain modified protein which
    34  are medically necessary, and such coverage for such modified solid  food
    35  products  for  any  calendar year or for any continuous period of twelve
    36  months for any insured individual shall not  exceed  two  thousand  five
    37  hundred  dollars. Coverage for infant and baby formulas for any calendar

    38  year or any continuous period of twelve months for any insured  individ-
    39  ual shall be no less than three thousand dollars.
    40    §  3. Subsection (y) of section 4303 of the insurance law, as added by
    41  chapter 177 of the laws of 1997, is amended to read as follows:
    42    (y) Every contract which  provides  coverage  for  prescription  drugs
    43  shall include coverage for the cost of enteral, infant and baby formulas
    44  for home use for which a physician or other licensed health care provid-
    45  er  legally  authorized  to prescribe under title eight of the education
    46  law has issued a written order. Such written order shall state that  the
    47  enteral,  infant  or baby formula is clearly medically necessary and has
    48  been proven effective as a disease-specific treatment regimen for  those

    49  individuals  who  are  or will become malnourished or suffer from disor-
    50  ders, which if left untreated, cause chronic disability, mental retarda-
    51  tion or death. Specific diseases for  which  enteral,  infant  and  baby
    52  formulas  have  been proven effective shall include, but are not limited
    53  to, inherited diseases of amino-acid or organic acid metabolism; Crohn's
    54  Disease; gastroesophageal reflux with failure to  thrive;  disorders  of
    55  gastrointestinal motility such as chronic intestinal pseudo-obstruction;
    56  and  multiple,  severe food allergies which if left untreated will cause
        A. 4492                             3
 
     1  malnourishment,  chronic  physical  disability,  mental  retardation  or
     2  death.   Enteral, infant and baby formulas which are medically necessary

     3  and taken under written order from a  physician  for  the  treatment  of
     4  specific  diseases  shall  be distinguished from nutritional supplements
     5  taken electively. Coverage for certain inherited diseases of amino  acid
     6  and  organic  acid metabolism shall include modified solid food products
     7  that are low protein,  or  which  contain  modified  protein  which  are
     8  medically  necessary,  and  such  coverage  for such modified solid food
     9  products for any calendar year or for any continuous  period  of  twelve
    10  months  for  any  insured  individual shall not exceed two thousand five
    11  hundred dollars. Coverage for infant and baby formulas for any  calendar
    12  year  or any continuous period of twelve months for any insured individ-
    13  ual shall be no less than three thousand dollars.
    14    § 4. The opening paragraph  of  paragraph  25  of  subsection  (b)  of

    15  section 4322 of the insurance law, as amended by chapter 554 of the laws
    16  of 2002, is amended to read as follows:
    17    Prescription  drugs,  obtained  at  a  participating  pharmacy under a
    18  prescription written by an in-plan or  out-of-plan  provider,  including
    19  contraceptive  drugs  or  devices  approved by the federal food and drug
    20  administration or generic equivalents approved as  substitutes  by  such
    21  food  and  drug administration [and], nutritional supplements (formulas)
    22  for the therapeutic treatment of phenylketonuria, branched-chain ketonu-
    23  ria, galactosemia and homocystinuria[, obtained at a participating phar-
    24  macy under a prescription written by an in-plan or out-of-plan provider]
    25  and infant and baby formulas for home use for which a physician or other

    26  licensed health care provider  legally  authorized  to  prescribe  under
    27  title  eight of the education law has issued a written order. Such writ-
    28  ten order shall state  that  the  infant  or  baby  formula  is  clearly
    29  medically  necessary and has been proven effective as a disease-specific
    30  treatment regimen for those individuals who are or will become  malnour-
    31  ished  or  suffer from disorders, which if left untreated, cause chronic
    32  physical disability, mental retardation or death. Specific diseases  for
    33  which infant and baby formulas have been proven effective shall include,
    34  but are not limited to, inherited diseases of amino acid or organic acid
    35  metabolism;  Crohn's  Disease;  gastroesophageal  reflux with failure to

    36  thrive; disorders of gastrointestinal motility such as chronic  intesti-
    37  nal  pseudo-obstruction;  and  multiple,  severe food allergies which if
    38  left untreated will cause malnourishment, chronic  physical  disability,
    39  mental  retardation  or  death.  Infant  and  baby  formulas  which  are
    40  medically necessary and taken under written order from a  physician  for
    41  the  treatment  of  specific diseases shall be distinguished from nutri-
    42  tional supplements taken electively. Coverage for infant and baby formu-
    43  las for any calendar year or any continuous period of twelve months  for
    44  any  insured  individual  shall  be no less than three thousand dollars.
    45  Health maintenance organizations, in addition to providing coverage  for

    46  prescription drugs at a participating pharmacy, may utilize a mail order
    47  prescription  drug program. Health maintenance organizations may provide
    48  prescription drugs pursuant to a drug formulary; however, health mainte-
    49  nance organizations must implement an appeals process so that the use of
    50  non-formulary prescription drugs may be  requested  by  a  physician  or
    51  other provider.
    52    §  5. This act shall take effect on the first of January next succeed-
    53  ing the date on which it shall have become a law and shall apply to  all
    54  policies and contracts issued, renewed, modified, altered, or amended on
    55  or after such date.