Senate File 179 - Introduced
SENATE FILE
BY WARD
(COMPANION TO HF 176)
Passed Senate, Date Passed House, 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 1953SS 81
6 av/sh/8
PAG LIN
1 1 Section 1. NEW SECTION. 514C.22 ENTERAL FORMULAS ==
1 2 COVERAGE.
1 3 1. Notwithstanding the uniformity of treatment
1 4 requirements of section 514C.6, a policy or contract providing
1 5 for third=party payment or prepayment of health or medical
1 6 expenses shall not exclude or restrict benefits for enteral
1 7 formulas for home use for which a practitioner licensed by law
1 8 to prescribe and administer prescription drugs has issued a
1 9 written order, if such policy or contract provides benefits
1 10 for other outpatient prescription drugs or devices. Such
1 11 written order must state that the enteral formula is medically
1 12 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 "Enteral formula" includes low=protein medical food and
1 23 metabolic formula prescribed for persons diagnosed with
1 24 phenylketonuria or other metabolic disorders. The
1 25 commissioner, by rule, shall further define enteral formula.
1 26 3. a. This section applies to the following classes of
1 27 third=party payment provider contracts or policies delivered,
1 28 issued for delivery, continued, or renewed in this state on or
1 29 after July 1, 2005:
1 30 (1) Individual or group accident and sickness insurance
1 31 providing coverage on an expense=incurred basis.
1 32 (2) Any individual or group hospital or medical service
1 33 contract issued pursuant to chapter 509, 514, or 514A.
1 34 (3) Any individual or group health maintenance
1 35 organization contract regulated under chapter 514B.
2 1 (4) Any other entity engaged in the business of insurance,
2 2 risk transfer, or risk retention, which is subject to the
2 3 jurisdiction of the commissioner.
2 4 (5) A plan established pursuant to chapter 509A for public
2 5 employees.
2 6 (6) An organized delivery system licensed by the director
2 7 of public health.
2 8 b. This section shall not apply to accident only,
2 9 specified disease, short=term hospital or medical, hospital
2 10 confinement indemnity, credit, dental, vision, Medicare
2 11 supplement, long=term care, basic hospital and medical=
2 12 surgical expense coverage as defined by the commissioner,
2 13 disability income insurance coverage, coverage issued as a
2 14 supplement to liability insurance, workers' compensation or
2 15 similar insurance, or automobile medical payment insurance.
2 16 EXPLANATION
2 17 This bill creates new Code section 514C.22 and provides
2 18 that a policy or contract providing for third=party payment or
2 19 prepayment of health or medical expenses which provides
2 20 coverage benefits for other outpatient prescription drugs or
2 21 devices shall not exclude or restrict coverage benefits for
2 22 enteral formulas for home use prescribed by a practitioner as
2 23 being medically necessary and proven effective as a disease=
2 24 specific treatment regimen for individuals who are or will
2 25 become malnourished or suffer from disorders, which, if left
2 26 untreated, will cause chronic physical disability, mental
2 27 retardation, or death.
2 28 The bill defines "enteral formula" as formulas which have
2 29 been proven effective for the treatment of specific diseases
2 30 including, but not limited to, inherited diseases of amino
2 31 acid or organic acid metabolism; Crohn's disease;
2 32 gastroesophageal reflux with failure to thrive; disorders of
2 33 gastrointestinal motility such as chronic intestinal pseudo=
2 34 obstruction; and multiple, severe food allergies which if left
2 35 untreated will cause malnourishment, chronic physical
3 1 disability, mental retardation, or death. "Enteral formula"
3 2 is defined to include low=protein medical food and metabolic
3 3 formula prescribed for persons diagnosed with phenylketonuria
3 4 or other metabolic disorders. The bill provides that the
3 5 commissioner, by rule, shall further define enteral formulas.
3 6 The bill provides that the new Code section applies to
3 7 third=party payment provider contracts, or policies delivered,
3 8 issued for delivery, continued, or renewed in this state on or
3 9 after July 1, 2005.
3 10 LSB 1953SS 81
3 11 av:rj/sh/8.1