S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   5053
 
                        2019-2020 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             February 7, 2019
                                ___________
 
 Introduced  by  M.  of  A.  JEAN-PIERRE,  ZEBROWSKI,  FERNANDEZ,  ORTIZ,
   GUNTHER, ENGLEBRIGHT,  WILLIAMS,  PICHARDO,  JOYNER,  TAYLOR,  MOSLEY,
   ARROYO,  DICKENS,  D'URSO,  SIMON, GOTTFRIED, 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 chapter 469 of the laws of 2018, 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. 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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD05414-02-9

 A. 5053                             2
 
 formulas which 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 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.  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 chapter 469 of the laws of 2018, 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. 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 which 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 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. 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 chapter 469 of the laws of 2018, 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. Specific diseases and disorders
 for which enteral, INFANT AND BABY formulas have been  proven  effective

 A. 5053                             3
 
 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  which  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, 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. 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

 A. 5053                             4
 
 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.