Bill S5034A-2011

Enacts "Hannah's law"; requires certain insurance policies to include coverage for the cost of enteral formulas for the treatment of eosinophilic disorders

Enacts "Hannah's law"; requires that every health insurance policy or contract which provides coverage for prescription drugs include coverage for the cost of enteral formulas for which a physician has issued a written order and which are medically necessary for the treatment of eosinophilic esophagitis and related eosinophilic disorders.

Details

Actions

  • May 23, 2012: referred to insurance
  • May 23, 2012: DELIVERED TO ASSEMBLY
  • May 23, 2012: PASSED SENATE
  • Apr 30, 2012: ADVANCED TO THIRD READING
  • Apr 26, 2012: 2ND REPORT CAL.
  • Apr 25, 2012: 1ST REPORT CAL.584
  • Mar 5, 2012: REPORTED AND COMMITTED TO FINANCE
  • Feb 24, 2012: PRINT NUMBER 5034A
  • Feb 24, 2012: AMEND AND RECOMMIT TO INSURANCE
  • Jan 4, 2012: REFERRED TO INSURANCE
  • May 2, 2011: REFERRED TO INSURANCE

Votes

VOTE: COMMITTEE VOTE: - Insurance - Mar 5, 2012
Ayes (17): Seward, Flanagan, Golden, Grisanti, Lanza, Larkin, LaValle, Martins, Saland, Young, Breslin, Diaz, Espaillat, Kennedy, Parker, Smith, Stavisky
Ayes W/R (1): Peralta

Memo

BILL NUMBER:S5034A

TITLE OF BILL: An act to amend the insurance law, in relation to requiring certain health insurance policies to include coverage for the cost of enteral formulas for the treatment of eosinophilic esophagitis and related eosinophilic disorders

PURPOSE: To update and modify existing laws requiring the coverage of enteral formulas.

SUMMARY OF PROVISIONS: Section 1: The short title - Hannah's Law.

Sections 2: Through four amend Insurance Law sections 3216(i) (21), 3221(11) and 4303(y), respectively, to specify that the existing requirements concerning coverage of enteral formulas under prescription drug plans is also applicable to policies providing medical, major medical or similar comprehensive-type coverage, whether administered orally or via tube feeding, and applicable to eosinophilic esophagitis and related eosiniphilic disorders. It also removes the existing $2,500 annual cap applicable to these enteral formulas.

Section 5: Makes a conforming amendment to Insurance Law section 4322(b) (25), applicable to standardized individual enrollee direct payment contracts offered by health maintenance organizations.

Section 6: Is the effective date.

JUSTIFICATION: This legislation is necessitated due to a flaw in existing Insurance Law regarding enteral formula coverage requirements encountered by the family of Hannah Devane. Hannah is a six year old girl who suffers from eosinophilic esophagitis, a potentially fatal condition that makes it impossible for her to eat most foods.

Children with eosinophilic esophagitis and similar disorders can only obtain nourishment from special, enteral formulas, which in some cases may be ingested orally but in other circumstances must be administered via a feeding tube. In the case of Hannah, the life sustaining formula can be taken orally and comes with a cost of approximately $1,200 per month, or $14,400 annually.

Hannah's medical insurance provider already provides coverage for the cost of enteral formulas, but only under conditions that require tube feeding. This company policy gives rise to the circumstance whereby Hanna's parents must incur significant out-of-pocket costs for the enteral formula needed to sustain her life, or choose to have the cost of the formula Covered but delivered through a feeding tube.

The purpose of Hannah's Law is to rectify this anomaly and to ensure. adequate coverage for those children with these rare diseases. It should also be noted that, pursuant to a 2006 settlement with the Attorney General, a different insurer was ordered to cease its denial of an enteral formula claim on the ground that a specific enteral formula was not tube fed.

LEGISLATIVE HISTORY: A.2188 of 2010.

FISCAL IMPLICATIONS: Miniscule cost to government health plans to expand an already existing health benefit requirement.

EFFECTIVE DATE: First of January next succeeding enactment and applicable to policies and contracts issued, renewed, modified, altered or amended on or after such date.


Text

STATE OF NEW YORK ________________________________________________________________________ 5034--A 2011-2012 Regular Sessions IN SENATE May 2, 2011 ___________
Introduced by Sen. BALL -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance -- recommitted to the Committee on Insurance in accordance with Senate Rule 6, sec. 8 -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee AN ACT to amend the insurance law, in relation to requiring certain health insurance policies to include coverage for the cost of enteral formulas for the treatment of eosinophilic esophagitis and related eosinophilic disorders THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Short title. This act shall be known and may be cited as "Hannah's law". S 2. 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 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 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; EOSINOPHILIC ESOPHAGITIS AND RELATED EOSINOPHILIC DISORDERS; 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 death. 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 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 indi- vidual shall not exceed two thousand five hundred dollars. S 3. 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 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 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; EOSINOPHILIC ESOPHAGITIS AND RELATED EOSINOPHILIC DISORDERS; 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 death. 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 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 indi- vidual shall not exceed two thousand five hundred dollars. S 4. 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 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 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; EOSINOPHILIC ESOPHAGITIS AND RELATED EOSINOPHILIC DISORDERS; 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 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. S 5. 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, 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 nutri- tional supplements (formulas), WHETHER ADMINISTERED ORALLY OR VIA A FEEDING TUBE for the therapeutic treatment of phenylketonuria, branched- chain ketonuria, galactosemia, EOSINOPHILIC ESOPHAGITIS AND RELATED EOSINOPHILIC DISORDERS, and homocystinuria, obtained at a participating pharmacy under a prescription written by an in-plan or out-of-plan provider. 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 6. 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.

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