House File 765 - Introduced
HOUSE FILE
BY COMMITTEE ON COMMERCE,
REGULATION AND LABOR
(SUCCESSOR TO HF 176)
Passed House, Date Passed Senate, Date
Vote: Ayes Nays Vote: Ayes Nays
Approved
A BILL FOR
1 An Act requiring every insurer offering certain individual or
2 group health insurance policies to provide coverage for
3 certain enteral formulas.
4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
5 TLSB 1953HV 81
6 av/sh/8
PAG LIN
1 1 Section 1. NEW SECTION. 514C.22 ENTERAL FORMULAS ==
1 2 COVERAGE.
1 3 1. Except as provided in subsections 4 and 5, and
1 4 notwithstanding the uniformity of treatment requirements of
1 5 section 514C.6, a policy or contract providing for third=
1 6 party payment or prepayment of health or medical expenses
1 7 shall not exclude or restrict benefits for enteral formulas
1 8 for home use for which a practitioner licensed by law to
1 9 prescribe and administer prescription drugs has issued a
1 10 written order, if such policy or contract provides benefits
1 11 for other outpatient prescription drugs or devices. Such
1 12 written order must state that the enteral formula is medically
1 13 necessary for the patient.
1 14 2. For purposes of this section, "enteral formula" means
1 15 enteral formulas which have been proven effective for the
1 16 treatment of inborn errors of metabolism with a dietary
1 17 restriction, which if left untreated will cause
1 18 malnourishment, chronic physical disability, mental
1 19 retardation, or death. "Enteral formula" includes low=protein
1 20 medical food and metabolic formula prescribed for persons
1 21 diagnosed with inborn errors of metabolism with a dietary
1 22 restriction. The commissioner, by rule, shall further define
1 23 enteral 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, 2005:
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) A plan established pursuant to chapter 509A for public
1 35 employees.
2 1 (5) An organized delivery system licensed by the director
2 2 of public health.
2 3 b. This section shall not apply to accident only,
2 4 specified disease, short=term hospital or medical, hospital
2 5 confinement indemnity, credit, dental, vision, Medicare
2 6 supplement, long=term care, basic hospital and medical=
2 7 surgical expense coverage as defined by the commissioner,
2 8 disability income insurance coverage, coverage issued as a
2 9 supplement to liability insurance, workers' compensation or
2 10 similar insurance, or automobile medical payment insurance.
2 11 4. An individual or group policy, contract, or plan
2 12 subject to the requirements of this section shall not impose
2 13 an annual deductible on enteral formula coverage benefits that
2 14 is greater than two thousand five hundred dollars per year for
2 15 each family covered and shall not impose an aggregate annual
2 16 limit for enteral formula coverage benefits that is less than
2 17 twelve thousand five hundred dollars per year for each family
2 18 covered.
2 19 5. An individual or group policy, contract, or plan
2 20 subject to the requirements of this section shall provide, at
2 21 a minimum, enteral formula coverage benefits to each male
2 22 insured until that individual reaches the age of twenty=one
2 23 years old or until that individual ceases to be enrolled as a
2 24 full=time student, as defined in section 261.102, whichever
2 25 occurs later, and shall provide, at a minimum, enteral formula
2 26 coverage benefits to each female insured until that individual
2 27 reaches the age of forty=five years old.
2 28 EXPLANATION
2 29 This bill creates new Code section 514C.22 and provides
2 30 that a policy or contract providing for third=party payment or
2 31 prepayment of health or medical expenses which provides
2 32 coverage benefits for other outpatient prescription drugs or
2 33 devices shall not exclude or restrict coverage benefits for
2 34 enteral formulas for home use prescribed by a practitioner as
2 35 being medically necessary and proven effective as a disease=
3 1 specific treatment regimen for individuals who are or will
3 2 become malnourished or suffer from disorders, which, if left
3 3 untreated, will cause chronic physical disability, mental
3 4 retardation, or death.
3 5 The bill defines "enteral formula" as formulas which have
3 6 been proven effective for the treatment of inborn errors of
3 7 metabolism with a dietary restriction which if left untreated
3 8 will cause malnourishment, chronic physical disability, mental
3 9 retardation, or death. "Enteral formula" is defined to
3 10 include low=protein medical food and metabolic formula
3 11 prescribed for persons diagnosed with inborn errors of
3 12 metabolism with a dietary restriction. The bill provides that
3 13 the commissioner, by rule, shall further define enteral
3 14 formulas.
3 15 The bill provides that the new Code section applies to
3 16 third=party payment provider contracts, or policies delivered,
3 17 issued for delivery, continued, or renewed in this state on or
3 18 after July 1, 2005.
3 19 The bill provides that an individual or group policy,
3 20 contract, or plan subject to the requirements of the bill
3 21 shall not impose an annual deductible on enteral formula
3 22 coverage benefits that exceed $2,500 per year for each family
3 23 covered and shall not impose an aggregate annual limit for
3 24 such benefits that is less than $12,500 per year for each
3 25 family covered.
3 26 The bill also provides that enteral formula coverage
3 27 benefits must be provided, at a minimum, to each male insured
3 28 until that individual reaches 21 years of age or ceases to be
3 29 enrolled as a full=time student, whichever occurs later, and
3 30 to each female insured until that individual reaches the age
3 31 of 45.
3 32 LSB 1953HV 81
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