S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1831
 
                        2021-2022 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 11, 2021
                                ___________
 
 Introduced  by  M.  of  A.  JEAN-PIERRE,  ZEBROWSKI, FERNANDEZ, GUNTHER,
   ENGLEBRIGHT, WILLIAMS, PICHARDO, JOYNER, TAYLOR, DICKENS, SIMON, GOTT-
   FRIED, BARRON, COOK, McDONOUGH, PEOPLES-STOKES, MONTESANO,  RICHARDSON
   --  Multi-Sponsored by -- M. of A. ABBATE -- 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 section 6 of subpart B of part J of chapter
 57 of the laws of 2019, is amended to read as follows:
   (21) Every policy that 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. Specific diseases and disorders
 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;
 disorders  of gastrointestinal motility such as chronic intestinal pseu-
 do-obstruction; and multiple, severe food allergies including,  but  not
 limited  to  immunoglobulin E and nonimmunoglobulin E-mediated allergies
 to multiple 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  motility  of  the  gastrointestinal tract. Enteral, INFANT AND BABY
 formulas that are medically necessary and taken under written order from
 a physician for the treatment of  specific  diseases  shall  be  distin-
 guished  from  nutritional  supplements  taken  electively. Coverage for
              

 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD04789-01-1

 A. 1831                             2
 
 certain inherited diseases of amino acid and organic acid metabolism  as
 well  as severe protein allergic conditions shall include modified solid
 food products that are low protein, contain  modified  protein,  or  are
 amino  acid  based that are medically necessary. 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.
   § 2. Paragraph 11 of subsection (k) of section 3221 of  the  insurance
 law,  as  amended  by section 14 of subpart B of part J of chapter 57 of
 the laws of 2019, is amended to read as follows:
   (11) Every policy that 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. Specific diseases and disorders
 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;
 disorders  of gastrointestinal motility such as chronic intestinal pseu-
 do-obstruction; and multiple, severe food allergies including,  but  not
 limited  to  immunoglobulin E and nonimmunoglobulin E-mediated allergies
 to multiple 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  motility  of  the  gastrointestinal tract. Enteral, INFANT AND BABY
 formulas that are medically necessary and taken under written order from
 a physician for the treatment of  specific  diseases  shall  be  distin-
 guished  from  nutritional  supplements  taken  electively. Coverage for
 certain inherited diseases of amino acid and organic acid metabolism  as
 well  as severe protein allergic conditions shall include modified solid
 food products that are low protein, contain  modified  protein,  or  are
 amino  acid  based that are medically necessary. 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.
   § 3. Subsection (y) of section 4303 of the insurance law,  as  amended
 by  section 27 of subpart B of part J of chapter 57 of the laws of 2019,
 is amended to read as follows:
   (y) Every contract that 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. Specific  diseases  and  disorders
 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;
 disorders of gastrointestinal motility such as chronic intestinal  pseu-
 do-obstruction;  and  multiple, severe food allergies including, but not
 limited to immunoglobulin E and nonimmunoglobulin  E-mediated  allergies
 to  multiple  food  proteins;  severe food protein induced enterocolitis

 A. 1831                             3
 
 syndrome; eosinophilic disorders; and impaired absorption  of  nutrients
 caused  by disorders affecting the absorptive surface, function, length,
 and motility of the gastrointestinal tract.  Enteral,  INFANT  AND  BABY
 formulas that are medically necessary and taken under written order from
 a  physician  for  the  treatment  of specific diseases shall be distin-
 guished from nutritional  supplements  taken  electively.  Coverage  for
 certain  inherited diseases of amino acid and organic acid metabolism as
 well as severe protein allergic conditions shall include modified  solid
 food  products  that  are  low protein, contain modified protein, or are
 amino acid based that are medically necessary. 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.
   §  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.
   §  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.