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.