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

                                  5282

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            February 22, 2013
                               ___________

Introduced  by  M. of A. MOYA -- 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
amino acid and organic acid metabolism shall include modified solid food

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD03064-01-3
              

A. 5282                             2

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
malnourishment,  chronic  physical  disability,  mental  retardation  or

A. 5282                             3

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.