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

                                  4492

                       2011-2012 Regular Sessions

                          I N  A S S E M B L Y

                            February 3, 2011
                               ___________

Introduced by M. of A. MENG, AUBRY, ROBINSON, JAFFEE, JEFFRIES, LANCMAN,
  KAVANAGH, J. RIVERA, SCARBOROUGH, WEPRIN, TITUS, GALEF, CASTRO, MAYER-
  SOHN,  ZEBROWSKI  -- Multi-Sponsored by -- M. of A. BARRON, GOTTFRIED,
  HOOPER, JOHNS, LAVINE,  LIFTON,  LUPARDO,  MARKEY,  McENENY,  MILLMAN,
  NOLAN,  PERRY,  PHEFFER,  WEISENBERG  -- 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:

  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-
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

              

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD07103-01-1

A. 4492                             2

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
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

A. 4492                             3

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.
  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.