STATE OF NEW YORK ________________________________________________________________________ 11043 IN ASSEMBLY 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: 1 Section 1. Paragraph 21 of subsection (i) of section 3216 of the 2 insurance law, as amended by chapter 388 of the laws of 2013, is amended 3 to read as follows: 4 (21) Every policy which provides coverage for prescription drugs shall 5 include coverage for the cost of enteral formulas for home use, whether 6 administered orally or via tube feeding, for which a physician or other 7 licensed health care provider legally authorized to prescribe under 8 title eight of the education law has issued a written order. Such writ- 9 ten order shall state that the enteral formula is clearly medically 10 necessary and has been proven effective as a disease-specific treatment 11 regimen [~~for those individuals who are or will become malnourished or~~ 12 ~~suffer from disorders, which if left untreated, cause chronic physical~~ 13 ~~disability, mental retardation or death~~]. Specific diseases and disor- 14 ders for which enteral formulas have been proven effective shall 15 include, but are not limited to, inherited diseases of amino acid or 16 organic acid metabolism; Crohn's Disease; gastroesophageal reflux [~~with~~ 17 ~~failure to thrive~~]; disorders of gastrointestinal motility such as 18 chronic intestinal pseudo-obstruction; and multiple, severe food aller- 19 gies [~~which if left untreated will cause malnourishment, chronic phys-~~ 20 ~~ical disability, mental retardation or death~~] including, but not limited 21 to immunoglobulin E and nonimmunoglobulin E-mediated allergies to multi- 22 ple food proteins; severe food protein induced enterocolitis syndrome; 23 eosinophilic disorders; and impaired absorption of nutrients caused by 24 disorders affecting the absorptive surface, function, length, and motil- 25 ity of the gastrointestinal tract. Enteral formulas which are medically 26 necessary and taken under written order from a physician for the treat- 27 ment of specific diseases shall be distinguished from nutritional 28 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 1 amino acid and organic acid metabolism as well as severe protein aller- 2 gic conditions shall include modified solid food products that are low 3 protein or which contain modified protein, or are amino acid based which 4 are medically necessary, and such coverage for such modified solid food 5 products for any calendar year or for any continuous period of twelve 6 months for any insured individual shall not exceed two thousand five 7 hundred dollars. 8 § 2. Paragraph 11 of subsection (k) of section 3221 of the insurance 9 law, as amended by chapter 388 of the laws of 2013, is amended to read 10 as follows: 11 (11) Every policy which provides coverage for prescription drugs shall 12 include coverage for the cost of enteral formulas for home use, whether 13 administered orally or via tube feeding, for which a physician or other 14 licensed health care provider legally authorized to prescribe under 15 title eight of the education law has issued a written order. Such writ- 16 ten order shall state that the enteral formula is clearly medically 17 necessary and has been proven effective as a disease-specific treatment 18 regimen [~~for those individuals who are or will become malnourished or~~ 19 ~~suffer from disorders, which if left untreated, cause chronic physical~~ 20 ~~disability, mental retardation or death~~]. Specific diseases and disor- 21 ders for which enteral formulas have been proven effective shall 22 include, but are not limited to, inherited diseases of amino-acid or 23 organic acid metabolism; Crohn's Disease; gastroesophageal reflux [~~with~~ 24 ~~failure to thrive~~]; disorders of gastrointestinal motility such as 25 chronic intestinal pseudo-obstruction; and multiple, severe food aller- 26 gies [~~which if left untreated will cause malnourishment, chronic phys-~~ 27 ~~ical disability, mental retardation or death~~] including, but not limited 28 to immunoglobulin E and nonimmunoglobulin E-mediated allergies to multi- 29 ple food proteins; severe food protein induced enterocolitis syndrome; 30 eosinophilic disorders and impaired absorption of nutrients caused by 31 disorders affecting the absorptive surface, function, length, and motil- 32 ity of the gastrointestinal tract. Enteral formulas which are medically 33 necessary and taken under written order from a physician for the treat- 34 ment of specific diseases shall be distinguished from nutritional 35 supplements taken electively. Coverage for certain inherited diseases of 36 amino acid and organic acid metabolism as well as severe protein aller- 37 gic conditions shall include modified solid food products that are low 38 protein or which contain modified protein, or are amino acid based which 39 are medically necessary, and such coverage for such modified solid food 40 products for any calendar year or for any continuous period of twelve 41 months for any insured individual shall not exceed two thousand five 42 hundred dollars. 43 § 3. Subsection (y) of section 4303 of the insurance law, as amended 44 by chapter 388 of the laws of 2013, is amended to read as follows: 45 (y) Every contract which provides coverage for prescription drugs 46 shall include coverage for the cost of enteral formulas for home use, 47 whether administered orally or via tube feeding, for which a physician 48 or other licensed health care provider legally authorized to prescribe 49 under title eight of the education law has issued a written order. Such 50 written order shall state that the enteral formula is clearly medically 51 necessary and has been proven effective as a disease-specific treatment 52 regimen [~~for those individuals who are or will become malnourished or~~ 53 ~~suffer from disorders, which if left untreated, cause chronic disabili-~~ 54 ~~ty, mental retardation or death~~]. Specific diseases and disorders for 55 which enteral formulas have been proven effective shall include, but are 56 not limited to, inherited diseases of amino-acid or organic acid meta-

A. 11043 3 1 bolism; Crohn's Disease; gastroesophageal reflux [~~with failure to~~ 2 ~~thrive~~]; disorders of gastrointestinal motility such as chronic intesti- 3 nal pseudo-obstruction; and multiple, severe food allergies [~~which if~~ 4 ~~left untreated will cause malnourishment, chronic physical disability,~~ 5 ~~mental retardation or death~~] including, but not limited to immunoglobu- 6 lin E and nonimmunoglobulin E-mediated allergies to multiple food prote- 7 ins; severe food protein induced enterocolitis syndrome; eosinophilic 8 disorders; and impaired absorption of nutrients caused by disorders 9 affecting the absorptive surface, function, length, and motility of the 10 gastrointestinal tract. Enteral formulas which are medically necessary 11 and taken under written order from a physician for the treatment of 12 specific diseases shall be distinguished from nutritional supplements 13 taken electively. Coverage for certain inherited diseases of amino acid 14 and organic acid metabolism as well as severe protein allergic condi- 15 tions shall include modified solid food products that are low protein, 16 or which contain modified protein, or are amino acid based which are 17 medically necessary, and such coverage for such modified solid food 18 products for any calendar year or for any continuous period of twelve 19 months for any insured individual shall not exceed two thousand five 20 hundred dollars. 21 § 4. This act shall take effect on the first of January next succeed- 22 ing the date on which it shall have become a law and shall apply to all 23 policies and contracts issued, renewed, modified, altered, or amended on 24 or after such date.

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