NY State Senate Bill 2009-S628

Senate Bill S628

2009-2010 Legislative Session

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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Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Actions

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2010	referred to insurance
Jan 09, 2009	referred to insurance

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2009-S628 (ACTIVE) - Details

See Assembly Version of this Bill:: A2188
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 3221, 4303 & 4322, Ins L
Versions Introduced in Other Legislative Sessions:: 2011-2012: S5034, A8413
2013-2014: S2287, A490

2009-S628 (ACTIVE) - Summary

Enacts "Hannah's law"; requires that every health insurance policy or contract which provides medical, major medical or similar comprehensive-type coverage or 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.

2009-S628 (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S628

 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
eosinophilic disorders


 PURPOSE OR GENERAL IDEA OF BILL :
To update and modify existing laws requiring the coverage of enteral
formulas.

 SUMMARY OF SPECIFIC PROVISIONS :
Section one is the short title Hannah's Law.

Sections two through four amend Insurance Law sections 3216(i) (21),
322100(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 five 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 six is the effective date.

 EFFECTS OF PRESENT LAW WHICH THIS BILL WOULD ALTER :
Existing law requires coverage of enteral formulas under plans
providing prescription drug benefits, subject to an annual maximum of
$2,500.  This legislation expands the applicability of the statute to
medical/major medical policies, clarifies that the coverage is
applicable to eosinophilic esophagitis and related eosiniphilic
disorders, and removes the annual monetary cap.

 JUSTIFICATION :
This legislation is necessitated because of an unusual flaw in
existing Insurance Law enteral formula coverage requirements
encountered by the family of Hannah Devane. Hannah is a three year old
girl who suffers from eosinophilic esophagitis, a potentially fatal
condition that makes it impossible for her to eat most foods.
Children with this 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.

 PRIOR LEGISLATIVE HISTORY :
New bill.
 FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS :
Miniscule cost to government health plans to expand an already
existing health benefit requirement.

 EFFECTIVE DATE :
January 1 next succeeding enactment and applicable to policies and
contracts issued, renewed, modified, altered or amended on or after
such date.

2009-S628 (ACTIVE) - Bill Text download pdf

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

                                   628

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                             January 9, 2009
                               ___________

Introduced  by  Sen. SAMPSON -- read twice and ordered printed, and when
  printed to be committed 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 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. 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 MEDICAL,  MAJOR  MEDICAL  OR  SIMILAR
COMPREHENSIVE-TYPE  COVERAGE  OR  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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD05214-01-9

S. 628                              2

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  neces-
sary[,  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  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 MEDICAL, MAJOR MEDICAL OR SIMILAR
COMPREHENSIVE-TYPE COVERAGE OR 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  neces-
sary[,  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  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 MEDICAL, MAJOR  MEDICAL  OR  SIMILAR
COMPREHENSIVE-TYPE  COVERAGE  OR  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 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-
testinal motility such as  chronic  intestinal  pseudo-obstruction;  and

S. 628                              3

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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