House Amendment 1635
PAG LIN
1 1 Amend Senate File 514, as amended, passed, and
1 2 reprinted by the Senate, as follows:
1 3 #1. Page 2, by striking lines 4 through 27 and
1 4 inserting the following:
1 5 <Sec. . NEW SECTION. 514C.24 ENTERAL FORMULAS
1 6 == COVERAGE.
1 7 1. Except as provided in subsections 4 and 5, and
1 8 notwithstanding the uniformity of treatment
1 9 requirements of section 514C.6, a contract, policy, or
1 10 plan providing for third=party payment or prepayment
1 11 of health or medical expenses shall not exclude or
1 12 restrict benefits for enteral formulas for home use
1 13 for which a practitioner licensed by law to prescribe
1 14 and administer prescription drugs has issued a written
1 15 order, if such contract, policy, or plan provides
1 16 benefits for other outpatient prescription drugs or
1 17 devices. Such written order must state that the
1 18 enteral formula is medically necessary for the
1 19 patient.
1 20 2. For purposes of this section, "enteral formula"
1 21 means enteral formulas which have been proven
1 22 effective for the treatment of inborn errors of
1 23 metabolism with a dietary restriction, which if left
1 24 untreated will cause malnourishment, chronic physical
1 25 disability, mental retardation, or death. "Enteral
1 26 formula" includes metabolic formulas prescribed for
1 27 persons diagnosed with inborn errors of metabolism
1 28 with a dietary restriction. The commissioner, by
1 29 rule, shall further define enteral formula.
1 30 3. a. This section applies to the following
1 31 classes of third=party payment provider contracts,
1 32 policies, or plans delivered, issued for delivery,
1 33 continued, or renewed in this state on or after
1 34 January 1, 2008:
1 35 (1) Individual or group accident and sickness
1 36 insurance providing coverage on an expense=incurred
1 37 basis.
1 38 (2) Any individual or group hospital or medical
1 39 service contract issued pursuant to chapter 509, 514,
1 40 or 514A.
1 41 (3) Any individual or group health maintenance
1 42 organization contract regulated under chapter 514B.
1 43 (4) A plan established pursuant to chapter 509A
1 44 for public employees.
1 45 (5) An organized delivery system licensed by the
1 46 director of public health.
1 47 b. This section shall not apply to accident=only,
1 48 specified disease, short=term hospital or medical,
1 49 hospital confinement indemnity, credit, dental,
1 50 vision, Medicare supplement, long=term care, basic
2 1 hospital and medical=surgical expense coverage as
2 2 defined by the commissioner, disability income
2 3 insurance coverage, coverage issued as a supplement to
2 4 liability insurance, workers' compensation or similar
2 5 insurance, or automobile medical payment insurance.
2 6 4. An individual or group contract, policy, or
2 7 plan subject to the requirements of this section shall
2 8 not impose an annual deductible on enteral formula
2 9 coverage benefits that is greater than two thousand
2 10 five hundred dollars per year for each family covered
2 11 and shall not impose an aggregate annual limit for
2 12 enteral formula coverage benefits that is less than
2 13 twelve thousand five hundred dollars per year for each
2 14 family covered.
2 15 5. An individual or group contract, policy, or
2 16 plan subject to the requirements of this section shall
2 17 provide, at a minimum, enteral formula coverage
2 18 benefits to each male insured until that individual
2 19 reaches the age of twenty=one years old or until that
2 20 individual ceases to be enrolled as a full=time
2 21 student, as defined in section 261.102, whichever
2 22 occurs later, and shall provide, at a minimum, enteral
2 23 formula coverage benefits to each female insured until
2 24 that individual reaches the age of forty=five years
2 25 old.
2 26 Sec. . NEW SECTION. 514C.25 AUDIOLOGICAL
2 27 SERVICES AND HEARING AIDS FOR CHILDREN == COVERAGE.
2 28 1. Notwithstanding the uniformity of treatment
2 29 requirements of section 514C.6, a contract, policy, or
2 30 plan providing for third=party payment or prepayment
2 31 of health or medical expenses shall provide minimum
2 32 coverage benefits for audiological services and
2 33 hearing aids for children, including but not limited
2 34 to the following classes of third=party payment
2 35 provider contracts, policies, or plans delivered,
2 36 issued for delivery, continued, or renewed in this
2 37 state on or after January 1, 2008:
2 38 a. Individual or group accident and sickness
2 39 insurance providing coverage on an expense=incurred
2 40 basis.
2 41 b. An individual or group hospital or medical
2 42 service contract issued pursuant to chapter 509, 514,
2 43 or 514A.
2 44 c. An individual or group health maintenance
2 45 organization contract regulated under chapter 514B.
2 46 d. An individual or group Medicare supplemental
2 47 policy, unless coverage pursuant to such policy is
2 48 preempted by federal law.
2 49 e. A plan established pursuant to chapter 509A for
2 50 public employees.
3 1 2. This section shall not apply to accident=only,
3 2 specified disease, short=term hospital or medical,
3 3 hospital confinement indemnity, credit, dental,
3 4 vision, long=term care, basic hospital and
3 5 medical=surgical expense coverage as defined by the
3 6 commissioner, disability income insurance coverage,
3 7 coverage issued as a supplement to liability
3 8 insurance, workers' compensation or similar insurance,
3 9 or automobile medical payment insurance.
3 10 3. As used in this section, "minimum coverage for
3 11 audiological services and hearing aids for children"
3 12 means coverage that includes at a minimum all of the
3 13 following:
3 14 a. Coverage for hearing aids that are prescribed,
3 15 filled and dispensed by a licensed audiologist for
3 16 children up to eighteen years of age.
3 17 b. Coverage for hearing aid dispensing services
3 18 provided by a hearing aid dispenser licensed pursuant
3 19 to chapter 154A for children up to eighteen years of
3 20 age.
3 21 c. Coverage for an ear mold and a hearing aid for
3 22 each hearing=impaired ear payable every twenty=four
3 23 months for children up to eighteen years of age and
3 24 coverage for up to four additional ear molds per year
3 25 for children up to three years of age.
3 26 4. The commissioner of insurance shall adopt rules
3 27 pursuant to chapter 17A as necessary to administer
3 28 this section.>
3 29 #2. Title page, lines 3, 4, and 5, by striking the
3 30 words <and requesting an interim study committee on
3 31 health benefit mandates> and inserting the following:
3 32 <, certain enteral formulas, and audiological services
3 33 and hearing aids for children>.
3 34 #3. By renumbering as necessary.
3 35
3 36
3 37
3 38 COMMITTEE ON HUMAN RESOURCES
3 39 SMITH of Marshall, Chairperson
3 40 SF 514.201 82
3 41 av/es/9181
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