S T A T E O F N E W Y O R K
________________________________________________________________________
10450--B
Cal. No. 846
I N A S S E M B L Y
March 26, 2010
___________
Introduced by M. of A. MENG, AUBRY, ROBINSON, JAFFEE, JEFFRIES, LANCMAN,
KAVANAGH, J. RIVERA, SCARBOROUGH, D. WEPRIN, TITUS, GALEF, CASTRO,
MAYERSOHN, ZEBROWSKI -- Multi-Sponsored by -- M. of A. BARRON, GOTT-
FRIED, HOOPER, HYER-SPENCER, JOHN, KOON, LAVINE, LIFTON, LUPARDO,
MARKEY, McENENY, MILLMAN, NOLAN, PERRY, PHEFFER, WEISENBERG -- read
once and referred to the Committee on Insurance -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee -- reported from committee, advanced to a third
reading, amended and ordered reprinted, retaining its place on the
order of third reading
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:
Section 1. 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, INFANT AND BABY formulas for
home use 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, INFANT OR BABY 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 disor-
ders, which if left untreated, cause chronic physical disability, mental
retardation or death. Specific diseases for which enteral, INFANT AND
BABY formulas have been proven effective shall include, but are not
limited to, inherited diseases of amino acid or organic acid metabolism;
Crohn's Disease; gastroesophageal reflux with failure to thrive; disor-
ders of gastrointestinal motility such as chronic intestinal pseudo-ob-
struction; and multiple, severe food allergies which if left untreated
will cause malnourishment, chronic physical disability, mental retarda-
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD16588-03-0
A. 10450--B 2
tion or death. Enteral, INFANT AND BABY formulas which are medically
necessary and taken under written order from a physician for the treat-
ment 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. COVERAGE FOR INFANT AND BABY FORMULAS FOR ANY CALENDAR
YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR ANY INSURED INDIVID-
UAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS.
S 2. 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, INFANT AND BABY formulas for
home use 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, INFANT OR BABY 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 disor-
ders, which if left untreated, cause chronic physical disability, mental
retardation or death. Specific diseases for which enteral, INFANT AND
BABY formulas have been proven effective shall include, but are not
limited to, inherited diseases of amino-acid or organic acid metabolism;
Crohn's Disease; gastroesophageal reflux with failure to thrive; disor-
ders of gastrointestinal motility such as chronic intestinal pseudo-ob-
struction; and multiple, severe food allergies which if left untreated
will cause malnourishment, chronic physical disability, mental retarda-
tion or death. Enteral, INFANT AND BABY formulas which are medically
necessary and taken under written order from a physician for the treat-
ment 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. COVERAGE FOR INFANT AND BABY FORMULAS FOR ANY CALENDAR
YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR ANY INSURED INDIVID-
UAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS.
S 3. 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, INFANT AND BABY formulas
for home use for which a physician or other licensed health care provid-
er legally authorized to prescribe under title eight of the education
law has issued a written order. Such written order shall state that the
enteral, INFANT OR BABY 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 disor-
ders, which if left untreated, cause chronic disability, mental retarda-
tion or death. Specific diseases for which enteral, INFANT AND BABY
formulas have been proven effective shall include, but are not limited
A. 10450--B 3
to, inherited diseases of amino-acid or organic acid metabolism; Crohn's
Disease; 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, INFANT AND BABY 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. COVERAGE FOR INFANT AND BABY FORMULAS FOR ANY CALENDAR
YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR ANY INSURED INDIVID-
UAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS.
S 4. 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, OBTAINED AT A PARTICIPATING PHARMACY UNDER A
PRESCRIPTION WRITTEN BY AN IN-PLAN OR OUT-OF-PLAN PROVIDER, 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], nutritional supplements (formulas)
for the therapeutic treatment of phenylketonuria, branched-chain ketonu-
ria, galactosemia and homocystinuria[, obtained at a participating phar-
macy under a prescription written by an in-plan or out-of-plan provider]
AND INFANT AND BABY FORMULAS FOR HOME USE 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 INFANT OR BABY FORMULA IS CLEARLY
MEDICALLY NECESSARY AND HAS BEEN PROVEN EFFECTIVE AS A DISEASE-SPECIFIC
TREATMENT REGIMEN FOR THOSE INDIVIDUALS WHO ARE OR WILL BECOME MALNOUR-
ISHED OR SUFFER FROM DISORDERS, WHICH IF LEFT UNTREATED, CAUSE CHRONIC
PHYSICAL DISABILITY, MENTAL RETARDATION OR DEATH. SPECIFIC DISEASES FOR
WHICH INFANT AND BABY FORMULAS HAVE BEEN PROVEN EFFECTIVE SHALL INCLUDE,
BUT ARE NOT LIMITED TO, INHERITED DISEASES OF AMINO ACID OR ORGANIC ACID
METABOLISM; CROHN'S DISEASE; GASTROESOPHAGEAL REFLUX WITH FAILURE TO
THRIVE; DISORDERS OF GASTROINTESTINAL MOTILITY SUCH AS CHRONIC INTESTI-
NAL PSEUDO-OBSTRUCTION; AND MULTIPLE, SEVERE FOOD ALLERGIES WHICH IF
LEFT UNTREATED WILL CAUSE MALNOURISHMENT, CHRONIC PHYSICAL DISABILITY,
MENTAL RETARDATION OR DEATH. INFANT AND BABY FORMULAS WHICH ARE
MEDICALLY NECESSARY AND TAKEN UNDER WRITTEN ORDER FROM A PHYSICIAN FOR
THE TREATMENT OF SPECIFIC DISEASES SHALL BE DISTINGUISHED FROM NUTRI-
TIONAL SUPPLEMENTS TAKEN ELECTIVELY. COVERAGE FOR INFANT AND BABY FORMU-
LAS FOR ANY CALENDAR YEAR OR ANY CONTINUOUS PERIOD OF TWELVE MONTHS FOR
ANY INSURED INDIVIDUAL SHALL BE NO LESS THAN THREE THOUSAND DOLLARS.
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 mainte-
nance organizations must implement an appeals process so that the use of
non-formulary prescription drugs may be requested by a physician or
other provider.
A. 10450--B 4
S 5. 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.