A05053 Summary:

BILL NOA05053
 
SAME ASSAME AS S02305
 
SPONSORJean-Pierre
 
COSPNSRZebrowski, Fernandez, Ortiz, Gunther, Englebright, Williams, Pichardo, Joyner, Taylor, Mosley, Arroyo, Dickens, D'Urso, Simon, Gottfried, Barron, Cook, McDonough, Peoples-Stokes, Montesano, Richardson, Jaffee
 
MLTSPNSRAbbate
 
Amd 3216, 3221, 4303 & 4322, Ins L
 
Requires certain health insurance policies to include coverage for the cost of certain infant and baby formulas.
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A05053 Actions:

BILL NOA05053
 
02/07/2019referred to insurance
01/08/2020referred to insurance
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A05053 Committee Votes:

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A05053 Floor Votes:

There are no votes for this bill in this legislative session.
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A05053 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A5053
 
SPONSOR: Jean-Pierre
  TITLE OF BILL: 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   PURPOSE OR GENERAL IDEA OF BILL: To allow parents to affordably provide medically necessary formulas for infants who would become malnourished or suffer from disorders if these particular formulas were made unavailable to them. These disorders, if left untreated, may cause chronic physical disability, mental retarda- tion or death.   SUMMARY OF PROVISIONS: This bill would require that coverage by any policy which provides coverage for prescription drugs must provide coverage for the cost of infant and baby formulas which are proven effective as a disease-specif- ic regimen. Such formulas must be prescribed by a physician or other licensed health care professional. Coverage for certain infant and baby formulas for twelve months shall not exceed $3,000.   DIFFERENCE BETWEEN ORIGINAL AND AMENDED VERSION (IF APPLICABLE):   JUSTIFICATION: Many infants have been prescribed medically necessary formulas which have been proven effective as a disease-specific treatment regimen for infants who are, or will become, malnourished or suffer from disorders, which, if left untreated, may cause chronic physical disability, mental retardation or death. Specific diseases for which infant formulas have been proven effective include: inherited diseases of amino acid, Crohn's disease, gastroesophageal reflux with failure to thrive, and multiple severe food allergies. Symptoms of such allergies may also include: loose stools which may contain blood, vomiting, hives, diar- rhea, abdominal cramps, coughing or wheezing, runny nose, watery eyes, itchy skin rash, often around the mouth; and colic. Infant and baby formula, which must be purchased to prevent symptoms from occurring, are more expensive than regular formulas. Especially during these difficult economic times, parents need help to provide the food that is best and safest for their infants. Currently, in New York State, insurance companies are not required to cover these medically necessary formulas. However, other states, such as Arizona, Colorado, Louisiana, and Massa- chusetts do have provisions which require insurance companies to cover such infant formulas.   PRIOR LEGISLATIVE HISTORY: A3732 of 2016 - referred to insurance 2013 A5282 - referred to Insurance A6206 - referred to Insurance   FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS: None to the state.   EFFECTIVE DATE: This act shall take effect on the first of January next succeeding the date on which it shall have become law and shall apply to all policies and contracts issues, renewed, modified, altered, or amended on or after such date.
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A05053 Text:



 
                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.
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