Text: SF02253 Text: SF02255 Text: SF02200 - SF02299 Text: SF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN
1 1 Section 1. NEW SECTION. 514C.21 ENTERAL FORMULAS –
1 2 COVERAGE.
1 3 1. Notwithstanding the uniformity of treatment
1 4 requirements of section 514C.6, a group policy or contract
1 5 providing for third-party payment or prepayment of health or
1 6 medical expenses shall not exclude or restrict benefits for
1 7 enteral formulas for home use for which a practitioner
1 8 licensed by law to prescribe and administer prescription drugs
1 9 has issued a written order, if such policy or contract
1 10 provides benefits for other outpatient prescription drugs or
1 11 devices. Such written order shall state that the enteral
1 12 formula is medically necessary for the patient.
1 13 2. For purposes of this section, "enteral formula" means
1 14 enteral formulas which have been proven effective for the
1 15 treatment of specific diseases including, but not limited to,
1 16 inherited diseases of amino acid or organic acid metabolism;
1 17 Crohn's disease; gastroesophageal reflux with failure to
1 18 thrive; disorders of gastrointestinal motility such as chronic
1 19 intestinal pseudo-obstruction; and multiple, severe food
1 20 allergies, which if left untreated will cause malnourishment,
1 21 chronic physical disability, mental retardation, or death.
1 22 The commissioner, by rule, shall further define enteral
1 23 formula.
1 24 3. a. This section applies to the following classes of
1 25 third-party payment provider contracts or policies delivered,
1 26 issued for delivery, continued, or renewed in this state on or
1 27 after July 1, 2002:
1 28 (1) Individual or group accident and sickness insurance
1 29 providing coverage on an expense-incurred basis.
1 30 (2) Any individual or group hospital or medical service
1 31 contract issued pursuant to chapter 509, 514, or 514A.
1 32 (3) Any individual or group health maintenance
1 33 organization contract regulated under chapter 514B.
1 34 (4) Any other entity engaged in the business of insurance,
1 35 risk transfer, or risk retention, which is subject to the
2 1 jurisdiction of the commissioner.
2 2 (5) A plan established pursuant to chapter 509A for public
2 3 employees.
2 4 (6) An organized delivery system licensed by the director
2 5 of public health.
2 6 b. This section shall not apply to accident only,
2 7 specified disease, short-term hospital or medical, hospital
2 8 confinement indemnity, credit, dental, vision, Medicare
2 9 supplement, long-term care, basis hospital and medical-
2 10 surgical expense coverage as defined by the commissioner,
2 11 disability income insurance coverage, coverage issued as a
2 12 supplement to liability insurance, workers' compensation or
2 13 similar insurance, or automobile medical payment insurance.
2 14 EXPLANATION
2 15 This bill creates new Code section 514C.21 and provides
2 16 that a group policy or contract providing for third-party
2 17 payment or prepayment of health or medical expenses which
2 18 provides coverage benefits for other outpatient prescription
2 19 drugs or devices shall not exclude or restrict coverage
2 20 benefits for enteral formulas for home use prescribed by a
2 21 practitioner as being medically necessary and proven effective
2 22 as a disease-specific treatment regimen for individuals who
2 23 are or will become malnourished or suffer from disorders,
2 24 which, if left untreated, will cause chronic physical
2 25 disability, mental retardation, or death.
2 26 The bill defines "enteral formula" as formulas which have
2 27 been proven effective for the treatment of specific diseases
2 28 including, but not limited to, inherited diseases of amino
2 29 acid or organic acid metabolism; Crohn's disease;
2 30 gastroesophageal reflux with failure to thrive; disorders of
2 31 gastrointestinal motility such as chronic intestinal pseudo-
2 32 obstruction; and multiple, severe food allergies which if left
2 33 untreated will cause malnourishment, chronic physical
2 34 disability, mental retardation, or death.
2 35 The bill provides that the commissioner, by rule, shall
3 1 further define enteral formulas. The bill provides that the
3 2 new Code section applies to third-party payment provider
3 3 contracts, or policies delivered, issued for delivery,
3 4 continued, or renewed in this state on or after July 1, 2002.
3 5 LSB 5051XS 79
3 6 av/hk/91
Text: SF02253 Text: SF02255 Text: SF02200 - SF02299 Text: SF Index Bills and Amendments: General Index Bill History: General Index
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