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

                                  3732

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                            January 27, 2015
                               ___________

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 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, INFANT AND BABY  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, INFANT AND  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  disorders,  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, inher-
ited diseases of amino acid or organic acid metabolism; Crohn's Disease;
gastroesophageal reflux with failure to thrive; disorders  of  gastroin-
testinal  motility  such  as  chronic intestinal pseudo-obstruction; and
multiple, severe food allergies which if left untreated will cause maln-
ourishment, 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 elec-
tively. Coverage for certain inherited diseases of amino acid and organ-
ic 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

              

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD06715-01-5

A. 3732                             2

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 INDIVIDUAL SHALL BE
NO LESS THAN THREE THOUSAND DOLLARS.
  S 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, INFANT AND BABY  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, INFANT AND  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  disorders,  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, inher-
ited diseases of amino-acid or organic acid metabolism; Crohn's Disease;
gastroesophageal reflux with failure to thrive; disorders  of  gastroin-
testinal  motility  such  as  chronic intestinal pseudo-obstruction; and
multiple, severe food allergies which if left untreated will cause maln-
ourishment, 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 elec-
tively. Coverage for certain inherited diseases of amino acid and organ-
ic 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.
COVERAGE FOR INFANT AND BABY FORMULAS  FOR  ANY  CALENDAR  YEAR  OR  ANY
CONTINUOUS  PERIOD  OF TWELVE MONTHS FOR ANY INSURED INDIVIDUAL SHALL BE
NO LESS THAN THREE THOUSAND DOLLARS.
  S 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, INFANT AND BABY 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, INFANT AND 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  disorders,  which  if  left
untreated,  cause  chronic  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; disorders of gastroin-
testinal motility such as  chronic  intestinal  pseudo-obstruction;  and
multiple, severe food allergies which if left untreated will cause maln-
ourishment,  chronic  physical  disability, mental retardation or death.

A. 3732                             3

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 elec-
tively. Coverage for certain inherited diseases of amino acid and organ-
ic  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 INDIVIDUAL 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 388 of the laws
of 2013, 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),
whether administered orally or via a feeding tube  for  the  therapeutic
treatment of phenylketonuria, branched-chain ketonuria, galactosemia and
homocystinuria[,   obtained   at   a   participating  pharmacy  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 WRITTEN ORDER
SHALL STATE THAT THE INFANT OR BABY FORMULA IS CLEARLY MEDICALLY  NECES-
SARY AND HAS BEEN PROVEN EFFECTIVE AS A DISEASE-SPECIFIC TREATMENT REGI-
MEN  FOR THOSE INDIVIDUALS WHO ARE OR WILL BECOME MALNOURISHED OR SUFFER
FROM DISORDERS, WHICH IF LEFT UNTREATED, CAUSE CHRONIC PHYSICAL DISABIL-
ITY, 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; 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.  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 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.  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 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.