STATE OF NEW YORK ________________________________________________________________________ 1234 2023-2024 Regular Sessions IN SENATE January 10, 2023 ___________ Introduced by Sen. BAILEY -- read twice and ordered printed, and when printed to be committed 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: 1 Section 1. Paragraph 21 of subsection (i) of section 3216 of the 2 insurance law, as amended by section 6 of subpart B of part J of chapter 3 57 of the laws of 2019, is amended to read as follows: 4 (21) Every policy that provides coverage for prescription drugs shall 5 include coverage for the cost of enteral, infant and baby formulas for 6 home use, whether administered orally or via tube feeding, for which a 7 physician or other licensed health care provider legally authorized to 8 prescribe under title eight of the education law has issued a written 9 order. Such written order shall state that the enteral, infant and baby 10 formula is clearly medically necessary and has been proven effective as 11 a disease-specific treatment regimen. Specific diseases and disorders 12 for which enteral, infant and baby formulas have been proven effective 13 shall include, but are not limited to, inherited diseases of amino acid 14 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux; 15 disorders of gastrointestinal motility such as chronic intestinal pseu- 16 do-obstruction; and multiple, severe food allergies including, but not 17 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies 18 to multiple food proteins; severe food protein induced enterocolitis 19 syndrome; eosinophilic disorders; and impaired absorption of nutrients 20 caused by disorders affecting the absorptive surface, function, length, 21 and motility of the gastrointestinal tract. Enteral, infant and baby 22 formulas that are medically necessary and taken under written order from 23 a physician for the treatment of specific diseases shall be distin- 24 guished from nutritional supplements taken electively. Coverage for EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD02931-01-3
S. 1234 2 1 certain inherited diseases of amino acid and organic acid metabolism as 2 well as severe protein allergic conditions shall include modified solid 3 food products that are low protein, contain modified protein, or are 4 amino acid based that are medically necessary. Coverage for infant and 5 baby formulas for any calendar year or any continuous period of twelve 6 months for any insured individual shall be no less than three thousand 7 dollars. 8 § 2. Paragraph 11 of subsection (k) of section 3221 of the insurance 9 law, as amended by section 14 of subpart B of part J of chapter 57 of 10 the laws of 2019, is amended to read as follows: 11 (11) Every policy that provides coverage for prescription drugs shall 12 include coverage for the cost of enteral, infant and baby formulas for 13 home use, whether administered orally or via tube feeding, for which a 14 physician or other licensed health care provider legally authorized to 15 prescribe under title eight of the education law has issued a written 16 order. Such written order shall state that the enteral, infant and baby 17 formula is clearly medically necessary and has been proven effective as 18 a disease-specific treatment regimen. Specific diseases and disorders 19 for which enteral, infant and baby formulas have been proven effective 20 shall include, but are not limited to, inherited diseases of amino-acid 21 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux; 22 disorders of gastrointestinal motility such as chronic intestinal pseu- 23 do-obstruction; and multiple, severe food allergies including, but not 24 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies 25 to multiple food proteins; severe food protein induced enterocolitis 26 syndrome; eosinophilic disorders and impaired absorption of nutrients 27 caused by disorders affecting the absorptive surface, function, length, 28 and motility of the gastrointestinal tract. Enteral, infant and baby 29 formulas that are medically necessary and taken under written order from 30 a physician for the treatment of specific diseases shall be distin- 31 guished from nutritional supplements taken electively. Coverage for 32 certain inherited diseases of amino acid and organic acid metabolism as 33 well as severe protein allergic conditions shall include modified solid 34 food products that are low protein, contain modified protein, or are 35 amino acid based that are medically necessary. Coverage for infant and 36 baby formulas for any calendar year or any continuous period of twelve 37 months for any insured individual shall be no less than three thousand 38 dollars. 39 § 3. Subsection (y) of section 4303 of the insurance law, as amended 40 by section 27 of subpart B of part J of chapter 57 of the laws of 2019, 41 is amended to read as follows: 42 (y) Every contract that provides coverage for prescription drugs shall 43 include coverage for the cost of enteral, infant and baby formulas for 44 home use, whether administered orally or via tube feeding, for which a 45 physician or other licensed health care provider legally authorized to 46 prescribe under title eight of the education law has issued a written 47 order. Such written order shall state that the enteral, infant and baby 48 formula is clearly medically necessary and has been proven effective as 49 a disease-specific treatment regimen. Specific diseases and disorders 50 for which enteral, infant and baby formulas have been proven effective 51 shall include, but are not limited to, inherited diseases of amino-acid 52 or organic acid metabolism; Crohn's Disease; gastroesophageal reflux; 53 disorders of gastrointestinal motility such as chronic intestinal pseu- 54 do-obstruction; and multiple, severe food allergies including, but not 55 limited to immunoglobulin E and nonimmunoglobulin E-mediated allergies 56 to multiple food proteins; severe food protein induced enterocolitis
S. 1234 3 1 syndrome; eosinophilic disorders; and impaired absorption of nutrients 2 caused by disorders affecting the absorptive surface, function, length, 3 and motility of the gastrointestinal tract. Enteral, infant and baby 4 formulas that are medically necessary and taken under written order from 5 a physician for the treatment of specific diseases shall be distin- 6 guished from nutritional supplements taken electively. Coverage for 7 certain inherited diseases of amino acid and organic acid metabolism as 8 well as severe protein allergic conditions shall include modified solid 9 food products that are low protein, contain modified protein, or are 10 amino acid based that are medically necessary. Coverage for infant and 11 baby formulas for any calendar year or any continuous period of twelve 12 months for any insured individual shall be no less than three thousand 13 dollars. 14 § 4. The opening paragraph of paragraph 25 of subsection (b) of 15 section 4322 of the insurance law, as amended by chapter 388 of the laws 16 of 2013, is amended to read as follows: 17 Prescription drugs, obtained at a participating pharmacy under a 18 prescription written by an in-plan or out-of-plan provider, including 19 contraceptive drugs or devices approved by the federal food and drug 20 administration or generic equivalents approved as substitutes by such 21 food and drug administration [and], nutritional supplements (formulas), 22 whether administered orally or via a feeding tube for the therapeutic 23 treatment of phenylketonuria, branched-chain ketonuria, galactosemia and 24 homocystinuria[, obtained at a participating pharmacy under a 25 prescription written by an in-plan or out-of-plan provider] and infant 26 and baby formulas for home use for which a physician or other licensed 27 health care provider legally authorized to prescribe under title eight 28 of the education law has issued a written order. Such written order 29 shall state that the infant or baby formula is clearly medically neces- 30 sary and has been proven effective as a disease-specific treatment regi- 31 men for those individuals who are or will become malnourished or suffer 32 from disorders, which if left untreated, cause chronic physical disabil- 33 ity, mental retardation or death. Specific diseases for which infant and 34 baby formulas have been proven effective shall include, but are not 35 limited to, inherited diseases of amino acid or organic acid metabolism; 36 Crohn's Disease; gastroesophageal reflux with failure to thrive; disor- 37 ders of gastrointestinal motility such as chronic intestinal pseudo-ob- 38 struction; and multiple, severe food allergies which if left untreated 39 will cause malnourishment, chronic physical disability, mental retarda- 40 tion or death. Infant and baby formulas which are medically necessary 41 and taken under written order from a physician for the treatment of 42 specific diseases shall be distinguished from nutritional supplements 43 taken electively. Coverage for infant and baby formulas for any calendar 44 year or any continuous period of twelve months for any insured individ- 45 ual shall be no less than three thousand dollars. Health maintenance 46 organizations, in addition to providing coverage for prescription drugs 47 at a participating pharmacy, may utilize a mail order prescription drug 48 program. Health maintenance organizations may provide prescription drugs 49 pursuant to a drug formulary; however, health maintenance organizations 50 must implement an appeals process so that the use of non-formulary 51 prescription drugs may be requested by a physician or other provider. 52 § 5. This act shall take effect on the first of January next succeed- 53 ing the date on which it shall have become a law and shall apply to all 54 policies and contracts issued, renewed, modified, altered, or amended on 55 or after such date.