senate Bill S5034A

Enacts "Hannah's law"; requires certain insurance policies to include coverage for the cost of enteral formulas for the treatment of eosinophilic disorders

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Bill Status


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor
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actions

  • 02 / May / 2011
    • REFERRED TO INSURANCE
  • 04 / Jan / 2012
    • REFERRED TO INSURANCE
  • 24 / Feb / 2012
    • AMEND AND RECOMMIT TO INSURANCE
  • 24 / Feb / 2012
    • PRINT NUMBER 5034A
  • 05 / Mar / 2012
    • REPORTED AND COMMITTED TO FINANCE
  • 25 / Apr / 2012
    • 1ST REPORT CAL.584
  • 26 / Apr / 2012
    • 2ND REPORT CAL.
  • 30 / Apr / 2012
    • ADVANCED TO THIRD READING
  • 23 / May / 2012
    • PASSED SENATE
  • 23 / May / 2012
    • DELIVERED TO ASSEMBLY
  • 23 / May / 2012
    • REFERRED TO INSURANCE

Summary

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 for which a physician has issued a written order and which are medically necessary for the treatment of eosinophilic esophagitis and related eosinophilic disorders.

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Bill Details

See Assembly Version of this Bill:
A8413A
Versions:
S5034
S5034A
Legislative Cycle:
2011-2012
Current Committee:
Assembly Insurance
Law Section:
Insurance Law
Laws Affected:
Amd ยงยง3216, 3221, 4303 & 4322, Ins L
Versions Introduced in Previous Legislative Cycles:
2009-2010: S628, A2188, S628
2007-2008: A11215

Sponsor Memo

BILL NUMBER:S5034A

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 enteral
formulas for the treatment of eosinophilic esophagitis and related eosi-
nophilic disorders

PURPOSE:
To update and modify existing laws requiring the coverage of enteral
formulas.

SUMMARY OF PROVISIONS:
Section 1: The short title - Hannah's Law.

Sections 2: Through four amend Insurance Law sections 3216(i) (21),
3221(11) and 4303(y), respectively, to specify that the existing
requirements concerning coverage of enteral formulas under prescription
drug plans is also applicable to policies providing medical, major
medical or similar comprehensive-type coverage, whether administered
orally or via tube feeding, and applicable to eosinophilic esophagitis
and related eosiniphilic disorders. It also removes the existing $2,500
annual cap applicable to these enteral formulas.

Section 5: Makes a conforming amendment to Insurance Law section 4322(b)
(25), applicable to standardized individual enrollee direct payment
contracts offered by health maintenance organizations.

Section 6: Is the effective date.

JUSTIFICATION:
This legislation is necessitated due to a flaw in existing Insurance Law
regarding enteral formula coverage requirements encountered by the fami-
ly of Hannah Devane. Hannah is a six year old girl who suffers from
eosinophilic esophagitis, a potentially fatal condition that makes it
impossible for her to eat most foods.

Children with eosinophilic esophagitis and similar disorders can only
obtain nourishment from special, enteral formulas, which in some cases
may be ingested orally but in other circumstances must be administered
via a feeding tube. In the case of Hannah, the life sustaining formula
can be taken orally and comes with a cost of approximately $1,200 per
month, or $14,400 annually.

Hannah's medical insurance provider already provides coverage for the
cost of enteral formulas, but only under conditions that require tube
feeding. This company policy gives rise to the circumstance whereby
Hanna's parents must incur significant out-of-pocket costs for the
enteral formula needed to sustain her life, or choose to have the cost
of the formula Covered but delivered through a feeding tube.

The purpose of Hannah's Law is to rectify this anomaly and to ensure.
adequate coverage for those children with these rare diseases. It should
also be noted that, pursuant to a 2006 settlement with the Attorney
General, a different insurer was ordered to cease its denial of an
enteral formula claim on the ground that a specific enteral formula was
not tube fed.

LEGISLATIVE HISTORY:
A.2188 of 2010.

FISCAL IMPLICATIONS:
Miniscule cost to government health plans to expand an already existing
health benefit requirement.

EFFECTIVE DATE:
First of January next succeeding enactment and applicable to policies
and contracts issued, renewed, modified, altered or amended on or after
such date.

view bill text
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 5034--A

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                               May 2, 2011
                               ___________

Introduced  by  Sen.  BALL  --  read twice and ordered printed, and when
  printed to be committed to the Committee on Insurance  --  recommitted
  to the Committee on Insurance in accordance with Senate Rule 6, sec. 8
  --  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 for the treatment of  eosinophilic  esophagitis  and  related
  eosinophilic disorders

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Short title.  This act shall be known and may be  cited  as
"Hannah's law".
  S  2.  Paragraph 21 of subsection (i) of section 3216 of the insurance
law, as added by chapter 177 of the laws of 1997, is amended to read  as
follows:
  (21) Every policy which provides coverage for prescription drugs shall
include  coverage for the cost of enteral formulas for home use, WHETHER
ADMINISTERED ORALLY OR VIA TUBE FEEDING, for which a physician or  other
licensed  health  care  provider  legally  authorized to prescribe under
title eight of the education law has issued a written order. Such  writ-
ten  order  shall  state  that  the enteral formula is clearly medically
necessary and has been proven effective as a disease-specific  treatment
regimen  for  those  individuals  who are or will become malnourished or
suffer from disorders, which if left untreated, cause  chronic  physical
disability,  mental  retardation  or  death. Specific diseases for which
enteral formulas have been proven effective shall include, but  are  not
limited to, inherited diseases of amino acid or organic acid metabolism;
Crohn's  Disease;  EOSINOPHILIC  ESOPHAGITIS  AND  RELATED  EOSINOPHILIC
DISORDERS; gastroesophageal reflux with failure to thrive; disorders  of
gastrointestinal motility such as chronic intestinal pseudo-obstruction;

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08040-02-2

S. 5034--A                          2

and  multiple,  severe food allergies which if left untreated will cause
malnourishment,  chronic  physical  disability,  mental  retardation  or
death.  Enteral  formulas  which are medically necessary and taken under
written  order  from  a physician for the treatment of specific diseases
shall be distinguished from nutritional  supplements  taken  electively.
Coverage  for  certain inherited diseases of amino acid and organic acid
metabolism shall include modified  solid  food  products  that  are  low
protein or which contain modified protein which are medically necessary,
and such coverage for such modified solid food products for any calendar
year or for any continuous period of twelve months for any insured indi-
vidual shall not exceed two thousand five hundred dollars.
  S  3.  Paragraph 11 of subsection (k) of section 3221 of the insurance
law, as added by chapter 177 of the laws of 1997, is amended to read  as
follows:
  (11) Every policy which provides coverage for prescription drugs shall
include  coverage for the cost of enteral formulas for home use, WHETHER
ADMINISTERED ORALLY OR VIA TUBE FEEDING, for which a physician or  other
licensed  health  care  provider  legally  authorized to prescribe under
title eight of the education law has issued a written order. Such  writ-
ten  order  shall  state  that  the enteral formula is clearly medically
necessary and has been proven effective as a disease-specific  treatment
regimen  for  those  individuals  who are or will become malnourished or
suffer from disorders, which if left untreated, cause  chronic  physical
disability,  mental  retardation  or  death. Specific diseases for which
enteral formulas have been proven effective shall include, but  are  not
limited to, inherited diseases of amino-acid or organic acid metabolism;
Crohn's  Disease;  EOSINOPHILIC  ESOPHAGITIS  AND  RELATED  EOSINOPHILIC
DISORDERS; gastroesophageal reflux with failure to thrive; disorders  of
gastrointestinal motility such as chronic intestinal pseudo-obstruction;
and  multiple,  severe food allergies which if left untreated will cause
malnourishment,  chronic  physical  disability,  mental  retardation  or
death.  Enteral  formulas  which are medically necessary and taken under
written order from a physician for the treatment  of  specific  diseases
shall  be  distinguished  from nutritional supplements taken electively.
Coverage for certain inherited diseases of amino acid and  organic  acid
metabolism  shall  include  modified  solid  food  products that are low
protein or which contain modified protein which are medically necessary,
and such coverage for such modified solid food products for any calendar
year or for any continuous period of twelve months for any insured indi-
vidual shall not exceed two thousand five hundred dollars.
  S 4. Subsection (y) of section 4303 of the insurance law, as added  by
chapter 177 of the laws of 1997, is amended to read as follows:
  (y)  Every  contract  which  provides  coverage for prescription drugs
shall include coverage for the cost of enteral formulas  for  home  use,
WHETHER  ADMINISTERED  ORALLY OR VIA TUBE FEEDING, for which a physician
or other licensed health care provider legally authorized  to  prescribe
under  title eight of the education law has issued a written order. Such
written order shall state that the enteral formula is clearly  medically
necessary  and has been proven effective as a disease-specific treatment
regimen for those individuals who are or  will  become  malnourished  or
suffer  from disorders, which if left untreated, cause chronic disabili-
ty, mental retardation or death. Specific  diseases  for  which  enteral
formulas  have  been proven effective shall include, but are not limited
to, inherited diseases of amino-acid or organic acid metabolism; Crohn's
Disease; EOSINOPHILIC ESOPHAGITIS AND  RELATED  EOSINOPHILIC  DISORDERS;
gastroesophageal  reflux  with failure to thrive; disorders of gastroin-

S. 5034--A                          3

testinal motility such as  chronic  intestinal  pseudo-obstruction;  and
multiple, severe food allergies which if left untreated will cause maln-
ourishment,  chronic  physical  disability, mental retardation or death.
Enteral  formulas  which are medically necessary and taken under written
order from a physician for the treatment of specific diseases  shall  be
distinguished  from  nutritional  supplements taken electively. Coverage
for certain inherited diseases of amino acid and organic acid metabolism
shall include modified solid food products  that  are  low  protein,  or
which  contain  modified protein which are medically necessary, and such
coverage for such modified solid food products for any calendar year  or
for  any  continuous  period of twelve months for any insured individual
shall not exceed two thousand five hundred dollars.
  S 5. The opening paragraph  of  paragraph  25  of  subsection  (b)  of
section 4322 of the insurance law, as amended by chapter 554 of the laws
of 2002, is amended to read as follows:
  Prescription  drugs, including contraceptive drugs or devices approved
by the federal food  and  drug  administration  or  generic  equivalents
approved  as substitutes by such food and drug administration and nutri-
tional supplements (formulas), WHETHER  ADMINISTERED  ORALLY  OR  VIA  A
FEEDING TUBE for the therapeutic treatment of phenylketonuria, branched-
chain  ketonuria,  galactosemia,  EOSINOPHILIC  ESOPHAGITIS  AND RELATED
EOSINOPHILIC DISORDERS, and homocystinuria, obtained at a  participating
pharmacy  under  a  prescription  written  by  an in-plan or out-of-plan
provider. Health maintenance organizations,  in  addition  to  providing
coverage for prescription drugs at a participating pharmacy, may utilize
a mail order prescription drug program. Health maintenance organizations
may  provide  prescription  drugs pursuant to a drug formulary; however,
health maintenance organizations must implement an  appeals  process  so
that  the  use of non-formulary prescription drugs may be requested by a
physician or other provider.
  S 6. This act shall take effect on the first of January next  succeed-
ing  the date on which it shall have become a law and shall apply to all
policies and contracts issued, renewed, modified, altered, or amended on
or after such date.

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