Senate File 2039 - Introduced
SENATE FILE
BY WARD and WARNSTADT
(COMPANION TO LSB 5819HH
BY MADDOX)
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 treatment of certain inborn errors of metabolism with a
4 dietary restriction.
5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
6 TLSB 5819SS 81
7 av/sh/8
PAG LIN
1 1 Section 1. NEW SECTION. 514C.23 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 a
1 14 formula which has been proven effective for the treatment of
1 15 inborn errors of metabolism with a dietary restriction, which
1 16 if left untreated will cause malnourishment, chronic physical
1 17 disability, mental retardation, or death. "Enteral formula"
1 18 includes low=protein medical food and metabolic formula
1 19 prescribed for persons diagnosed with inborn errors of
1 20 metabolism with a dietary restriction. The commissioner, by
1 21 rule, shall further define "enteral formula".
1 22 3. a. This section applies to the following classes of
1 23 third=party payment provider contracts or policies delivered,
1 24 issued for delivery, continued, or renewed in this state on or
1 25 after July 1, 2006:
1 26 (1) Individual or group accident and sickness insurance
1 27 providing coverage on an expense=incurred basis.
1 28 (2) Any individual or group hospital or medical service
1 29 contract issued pursuant to chapter 509, 514, or 514A.
1 30 (3) Any individual or group health maintenance
1 31 organization contract regulated under chapter 514B.
1 32 (4) Any other entity engaged in the business of insurance,
1 33 risk transfer, or risk retention, which is subject to the
1 34 jurisdiction of the commissioner.
1 35 (5) A plan established pursuant to chapter 509A for public
2 1 employees.
2 2 (6) An organized delivery system licensed by the director
2 3 of public health.
2 4 b. This section shall not apply to accident only,
2 5 specified disease, short=term hospital or medical, hospital
2 6 confinement indemnity, credit, dental, vision, Medicare
2 7 supplement, long=term care, basic hospital and medical=
2 8 surgical expense coverage as defined by the commissioner,
2 9 disability income insurance coverage, coverage issued as a
2 10 supplement to liability insurance, workers' compensation or
2 11 similar insurance, or automobile medical payment insurance.
2 12 EXPLANATION
2 13 This bill creates new Code section 514C.23 and provides
2 14 that a policy or contract providing for third=party payment or
2 15 prepayment of health or medical expenses which provides
2 16 coverage benefits for other outpatient prescription drugs or
2 17 devices shall not exclude or restrict coverage benefits for
2 18 enteral formulas for home use prescribed by a practitioner as
2 19 being medically necessary and proven effective as a disease=
2 20 specific treatment regimen for individuals who are or will
2 21 become malnourished or suffer from disorders, which, if left
2 22 untreated, will cause chronic physical disability, mental
2 23 retardation, or death.
2 24 The bill defines "enteral formula" as a formula which has
2 25 been proven effective for the treatment of inborn errors of
2 26 metabolism with a dietary restriction which if left untreated
2 27 will cause malnourishment, chronic physical disability, mental
2 28 retardation, or death. "Enteral formula" is defined to
2 29 include low=protein medical food and metabolic formula
2 30 prescribed for persons diagnosed with inborn errors of
2 31 metabolism with a dietary restriction. The bill provides that
2 32 the commissioner, by rule, shall further define "enteral
2 33 formula".
2 34 The bill provides that the new Code section applies to
2 35 third=party payment provider contracts, or policies delivered,
3 1 issued for delivery, continued, or renewed in this state on or
3 2 after July 1, 2006.
3 3 LSB 5819SS 81
3 4 av:nh/sh/8