STATE OF NEW YORK
________________________________________________________________________
5053
2019-2020 Regular Sessions
IN ASSEMBLY
February 7, 2019
___________
Introduced by M. of A. JEAN-PIERRE, ZEBROWSKI, FERNANDEZ, ORTIZ,
GUNTHER, ENGLEBRIGHT, WILLIAMS, PICHARDO, JOYNER, TAYLOR, MOSLEY,
ARROYO, DICKENS, D'URSO, SIMON, GOTTFRIED, BARRON, COOK, McDONOUGH,
PEOPLES-STOKES, MONTESANO, RICHARDSON -- Multi-Sponsored by -- M. of
A. ABBATE -- 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 amended by chapter 469 of the laws of 2018, 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. 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
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD05414-02-9
A. 5053 2
1 formulas which are medically necessary and taken under written order
2 from a physician for the treatment of specific diseases shall be distin-
3 guished from nutritional supplements taken electively. Coverage for
4 certain inherited diseases of amino acid and organic acid metabolism as
5 well as severe protein allergic conditions shall include modified solid
6 food products that are low protein or which contain modified protein, or
7 are amino acid based which are medically necessary, and such coverage
8 for such modified solid food products for any calendar year or for any
9 continuous period of twelve months for any insured individual shall not
10 exceed two thousand five hundred dollars. Coverage for infant and baby
11 formulas for any calendar year or any continuous period of twelve months
12 for any insured individual shall be no less than three thousand dollars.
13 § 2. Paragraph 11 of subsection (k) of section 3221 of the insurance
14 law, as amended by chapter 469 of the laws of 2018, is amended to read
15 as follows:
16 (11) Every policy which provides coverage for prescription drugs shall
17 include coverage for the cost of enteral, infant and baby formulas for
18 home use, whether administered orally or via tube feeding, for which a
19 physician or other licensed health care provider legally authorized to
20 prescribe under title eight of the education law has issued a written
21 order. Such written order shall state that the enteral, infant and baby
22 formula is clearly medically necessary and has been proven effective as
23 a disease-specific treatment regimen. Specific diseases and disorders
24 for which enteral, infant and baby formulas have been proven effective
25 shall include, but are not limited to, inherited diseases of amino-acid
26 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux;
27 disorders of gastrointestinal motility such as chronic intestinal pseu-
28 do-obstruction; and multiple, severe food allergies including, but not
29 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies
30 to multiple food proteins; severe food protein induced enterocolitis
31 syndrome; eosinophilic disorders and impaired absorption of nutrients
32 caused by disorders affecting the absorptive surface, function, length,
33 and motility of the gastrointestinal tract. Enteral, infant and baby
34 formulas which are medically necessary and taken under written order
35 from a physician for the treatment of specific diseases shall be distin-
36 guished from nutritional supplements taken electively. Coverage for
37 certain inherited diseases of amino acid and organic acid metabolism as
38 well as severe protein allergic conditions shall include modified solid
39 food products that are low protein or which contain modified protein, or
40 are amino acid based which are medically necessary, and such coverage
41 for such modified solid food products for any calendar year or for any
42 continuous period of twelve months for any insured individual shall not
43 exceed two thousand five hundred dollars. Coverage for infant and baby
44 formulas for any calendar year or any continuous period of twelve months
45 for any insured individual shall be no less than three thousand dollars.
46 § 3. Subsection (y) of section 4303 of the insurance law, as amended
47 by chapter 469 of the laws of 2018, is amended to read as follows:
48 (y) Every contract which provides coverage for prescription drugs
49 shall include coverage for the cost of enteral, infant and baby formulas
50 for home use, whether administered orally or via tube feeding, for which
51 a physician or other licensed health care provider legally authorized to
52 prescribe under title eight of the education law has issued a written
53 order. Such written order shall state that the enteral, infant and baby
54 formula is clearly medically necessary and has been proven effective as
55 a disease-specific treatment regimen. Specific diseases and disorders
56 for which enteral, infant and baby formulas have been proven effective
A. 5053 3
1 shall include, but are not limited to, inherited diseases of amino-acid
2 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux;
3 disorders of gastrointestinal motility such as chronic intestinal pseu-
4 do-obstruction; and multiple, severe food allergies including, but not
5 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies
6 to multiple food proteins; severe food protein induced enterocolitis
7 syndrome; eosinophilic disorders; and impaired absorption of nutrients
8 caused by disorders affecting the absorptive surface, function, length,
9 and motility of the gastrointestinal tract. Enteral, infant and baby
10 formulas which are medically necessary and taken under written order
11 from a physician for the treatment of specific diseases shall be distin-
12 guished from nutritional supplements taken electively. Coverage for
13 certain inherited diseases of amino acid and organic acid metabolism as
14 well as severe protein allergic conditions shall include modified solid
15 food products that are low protein, or which contain modified protein,
16 or are amino acid based which are medically necessary, and such coverage
17 for such modified solid food products for any calendar year or for any
18 continuous period of twelve months for any insured individual shall not
19 exceed two thousand five hundred dollars. Coverage for infant and baby
20 formulas for any calendar year or any continuous period of twelve months
21 for any insured individual shall be no less than three thousand dollars.
22 § 4. The opening paragraph of paragraph 25 of subsection (b) of
23 section 4322 of the insurance law, as amended by chapter 388 of the laws
24 of 2013, is amended to read as follows:
25 Prescription drugs, obtained at a participating pharmacy under a
26 prescription written by an in-plan or out-of-plan provider, including
27 contraceptive drugs or devices approved by the federal food and drug
28 administration or generic equivalents approved as substitutes by such
29 food and drug administration [and], nutritional supplements (formulas),
30 whether administered orally or via a feeding tube for the therapeutic
31 treatment of phenylketonuria, branched-chain ketonuria, galactosemia and
32 homocystinuria[, obtained at a participating pharmacy under a
33 prescription written by an in-plan or out-of-plan provider] and infant
34 and baby formulas for home use for which a physician or other licensed
35 health care provider legally authorized to prescribe under title eight
36 of the education law has issued a written order. Such written order
37 shall state that the infant or baby formula is clearly medically neces-
38 sary and has been proven effective as a disease-specific treatment regi-
39 men for those individuals who are or will become malnourished or suffer
40 from disorders, which if left untreated, cause chronic physical disabil-
41 ity, mental retardation or death. Specific diseases for which infant and
42 baby formulas have been proven effective shall include, but are not
43 limited to, inherited diseases of amino acid or organic acid metabolism;
44 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor-
45 ders of gastrointestinal motility such as chronic intestinal pseudo-ob-
46 struction; and multiple, severe food allergies which if left untreated
47 will cause malnourishment, chronic physical disability, mental retarda-
48 tion or death. Infant and baby formulas which are medically necessary
49 and taken under written order from a physician for the treatment of
50 specific diseases shall be distinguished from nutritional supplements
51 taken electively. Coverage for infant and baby formulas for any calendar
52 year or any continuous period of twelve months for any insured individ-
53 ual shall be no less than three thousand dollars. Health maintenance
54 organizations, in addition to providing coverage for prescription drugs
55 at a participating pharmacy, may utilize a mail order prescription drug
56 program. Health maintenance organizations may provide prescription drugs
A. 5053 4
1 pursuant to a drug formulary; however, health maintenance organizations
2 must implement an appeals process so that the use of non-formulary
3 prescription drugs may be requested by a physician or other provider.
4 § 5. This act shall take effect on the first of January next succeed-
5 ing the date on which it shall have become a law and shall apply to all
6 policies and contracts issued, renewed, modified, altered, or amended on
7 or after such date.