S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   11043
 
                           I N  A S S E M B L Y
 
                               May 31, 2018
                                ___________
 
 Introduced  by  COMMITTEE  ON RULES -- (at request of M. of A. Stern) --
   read once and referred to the Committee on Insurance
 
 AN ACT to amend the insurance law, in relation to insurance coverage for
   enteral formula
 
   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 amended by chapter 388 of the laws of 2013, 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  AND  DISOR-
 DERS  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; gastroesophageal reflux [with
 failure to thrive];  disorders  of  gastrointestinal  motility  such  as
 chronic  intestinal pseudo-obstruction; and multiple, severe food aller-
 gies [which if left untreated will cause malnourishment,  chronic  phys-
 ical disability, mental retardation or death] INCLUDING, BUT NOT LIMITED
 TO IMMUNOGLOBULIN E AND NONIMMUNOGLOBULIN E-MEDIATED ALLERGIES TO MULTI-
 PLE  FOOD  PROTEINS; SEVERE FOOD PROTEIN INDUCED ENTEROCOLITIS SYNDROME;
 EOSINOPHILIC DISORDERS; AND IMPAIRED ABSORPTION OF NUTRIENTS  CAUSED  BY
 DISORDERS AFFECTING THE ABSORPTIVE SURFACE, FUNCTION, LENGTH, AND MOTIL-
 ITY OF THE GASTROINTESTINAL TRACT.  Enteral 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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD16153-01-8

 A. 11043                            2
 
 amino  acid and organic acid metabolism AS WELL AS SEVERE PROTEIN ALLER-
 GIC CONDITIONS shall include modified solid food products that  are  low
 protein or which contain modified protein, OR ARE AMINO ACID BASED 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.
   § 2. Paragraph 11 of subsection (k) of section 3221 of  the  insurance
 law,  as  amended by chapter 388 of the laws of 2013, 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  AND  DISOR-
 DERS  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; gastroesophageal reflux [with
 failure to thrive];  disorders  of  gastrointestinal  motility  such  as
 chronic  intestinal pseudo-obstruction; and multiple, severe food aller-
 gies [which if left untreated will cause malnourishment,  chronic  phys-
 ical disability, mental retardation or death] INCLUDING, BUT NOT LIMITED
 TO IMMUNOGLOBULIN E AND NONIMMUNOGLOBULIN E-MEDIATED ALLERGIES TO MULTI-
 PLE  FOOD  PROTEINS; SEVERE FOOD PROTEIN INDUCED ENTEROCOLITIS SYNDROME;
 EOSINOPHILIC DISORDERS AND IMPAIRED ABSORPTION OF  NUTRIENTS  CAUSED  BY
 DISORDERS AFFECTING THE ABSORPTIVE SURFACE, FUNCTION, LENGTH, AND MOTIL-
 ITY  OF THE GASTROINTESTINAL TRACT. Enteral 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 AS WELL AS SEVERE PROTEIN  ALLER-
 GIC  CONDITIONS  shall include modified solid food products that are low
 protein or which contain modified protein, OR ARE AMINO ACID BASED 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.
   §  3.  Subsection (y) of section 4303 of the insurance law, as amended
 by chapter 388 of the laws of 2013, 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 AND DISORDERS for
 which enteral formulas have been proven effective shall include, but are
 not limited to, inherited diseases of amino-acid or organic  acid  meta-

 A. 11043                            3
 
 bolism;  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] INCLUDING, BUT NOT LIMITED TO  IMMUNOGLOBU-
 LIN E AND NONIMMUNOGLOBULIN E-MEDIATED ALLERGIES TO MULTIPLE FOOD PROTE-
 INS;  SEVERE  FOOD  PROTEIN INDUCED ENTEROCOLITIS SYNDROME; EOSINOPHILIC
 DISORDERS; AND IMPAIRED ABSORPTION  OF  NUTRIENTS  CAUSED  BY  DISORDERS
 AFFECTING  THE ABSORPTIVE SURFACE, FUNCTION, LENGTH, AND MOTILITY OF THE
 GASTROINTESTINAL TRACT. 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 AS WELL AS SEVERE  PROTEIN  ALLERGIC  CONDI-
 TIONS  shall  include modified solid food products that are low protein,
 or which contain modified protein, OR ARE AMINO  ACID  BASED  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.
   § 4. 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.