House Study Bill 161 PAG LIN 1 1 Section 1. NEW SECTION. 514C.23 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 contract, policy, or plan providing for 1 6 third=party payment or prepayment of health or medical 1 7 expenses shall not exclude or restrict benefits for enteral 1 8 formulas for home use for which a practitioner licensed by law 1 9 to prescribe and administer prescription drugs has issued a 1 10 written order, if such contract, policy, or plan provides 1 11 benefits for other outpatient prescription drugs or devices. 1 12 Such written order must state that the enteral formula is 1 13 medically 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, policies, or plans 1 26 delivered, issued for delivery, continued, or renewed in this 1 27 state on or after January 1, 2008: 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 contract, policy, 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 contract, policy, 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 Sec. 2. NEW SECTION. 514C.24 AUDIOLOGICAL SERVICES AND 2 29 HEARING AIDS FOR CHILDREN == COVERAGE. 2 30 1. Notwithstanding the uniformity of treatment 2 31 requirements of section 514C.6, a contract, policy, or plan 2 32 providing for third=party payment or prepayment of health or 2 33 medical expenses shall provide minimum coverage benefits for 2 34 audiological services and hearing aids for children, including 2 35 but not limited to the following classes of third=party 3 1 payment provider contracts, policies, or plans delivered, 3 2 issued for delivery, continued, or renewed in this state on or 3 3 after January 1, 2008: 3 4 a. Individual or group accident and sickness insurance 3 5 providing coverage on an expense=incurred basis. 3 6 b. An individual or group hospital or medical service 3 7 contract issued pursuant to chapter 509, 514, or 514A. 3 8 c. An individual or group health maintenance organization 3 9 contract regulated under chapter 514B. 3 10 d. An individual or group Medicare supplemental policy, 3 11 unless coverage pursuant to such policy is preempted by 3 12 federal law. 3 13 e. A plan established pursuant to chapter 509A for public 3 14 employees. 3 15 2. This section shall not apply to accident=only, 3 16 specified disease, short=term hospital or medical, hospital 3 17 confinement indemnity, credit, dental, vision, long=term care, 3 18 basic hospital and medical=surgical expense coverage as 3 19 defined by the commissioner, disability income insurance 3 20 coverage, coverage issued as a supplement to liability 3 21 insurance, workers' compensation or similar insurance, or 3 22 automobile medical payment insurance. 3 23 3. As used in this section, "minimum coverage for 3 24 audiological services and hearing aids for children" means 3 25 coverage that includes at a minimum both of the following: 3 26 a. Coverage for hearing aids that are prescribed, filled 3 27 and dispensed by a licensed audiologist for children up to 3 28 eighteen years of age. 3 29 b. Coverage for an ear mold and a hearing aid for each 3 30 hearing=impaired ear payable every twenty=four months for 3 31 children up to eighteen years of age and coverage for up to 3 32 four additional ear molds per year for children up to three 3 33 years of age. 3 34 4. The commissioner of insurance shall adopt rules 3 35 pursuant to chapter 17A as necessary to administer this 4 1 section. 4 2 Sec. 3. NEW SECTION. 514C.25 HUMAN PAPILLOMA VIRUS 4 3 VACCINATIONS == COVERAGE. 4 4 1. Notwithstanding the uniformity of treatment 4 5 requirements of section 514C.6, a contract, policy, or plan 4 6 providing for third=party payment or prepayment of health or 4 7 medical expenses that provides coverage benefits for any 4 8 vaccination or immunization shall provide coverage benefits 4 9 for vaccinations for the human papilloma virus, to each female 4 10 insured who is nine years of age or older until that 4 11 individual reaches twenty=six years of age, including but not 4 12 limited to the following classes of third=party payment 4 13 provider contracts, policies, or plans delivered, issued for 4 14 delivery, continued, or renewed in this state on or after 4 15 January 1, 2008: 4 16 a. Individual or group accident and sickness insurance 4 17 providing coverage on an expense=incurred basis. 4 18 b. An individual or group hospital or medical service 4 19 contract issued pursuant to chapter 509, 514, or 514A. 4 20 c. An individual or group health maintenance organization 4 21 contract regulated under chapter 514B. 4 22 d. An individual or group Medicare supplemental policy, 4 23 unless coverage pursuant to such policy is preempted by 4 24 federal law. 4 25 e. A plan established pursuant to chapter 509A for public 4 26 employees. 4 27 2. This section shall not apply to accident only, 4 28 specified disease, short=term hospital or medical, hospital 4 29 confinement indemnity, credit, dental, vision, long=term care, 4 30 basic hospital and medical=surgical expense coverage as 4 31 defined by the commissioner, disability income insurance 4 32 coverage, coverage issued as a supplement to liability 4 33 insurance, workers' compensation or similar insurance, or 4 34 automobile medical payment insurance. 4 35 3. As used in this section, "human papilloma virus" means 5 1 the human papilloma virus as defined by the centers for 5 2 disease control and prevention of the United States department 5 3 of health and human services. 5 4 4. The commissioner of insurance shall adopt rules 5 5 pursuant to chapter 17A as necessary to administer this 5 6 section. 5 7 EXPLANATION 5 8 This bill requires insurers offering certain individual or 5 9 group health insurance contracts, policies, or plans in the 5 10 state to provide coverage for certain enteral formulas, 5 11 audiological services and hearing aids for children, and 5 12 vaccinations for human papilloma virus. 5 13 The provisions of the bill are applicable to third=party 5 14 payment provider contracts, policies, or plans delivered, 5 15 issued for delivery, continued, or renewed in this state on or 5 16 after January 1, 2008. 5 17 The commissioner of insurance is required to adopt rules 5 18 under Code chapter 17A to administer the provisions of the 5 19 bill. 5 20 ENTERAL FORMULAS. New Code section 514C.23 requires 5 21 specified individual and group health insurance contracts, 5 22 policies, or plans that provide coverage for outpatient 5 23 prescription drugs or devices to also provide coverage for 5 24 certain enteral formulas that have been prescribed by a 5 25 licensed medical practitioner for the treatment of inborn 5 26 errors of metabolism with a dietary restriction which if left 5 27 untreated will cause malnourishment, chronic physical 5 28 disability, mental retardation, or death. 5 29 The bill prohibits imposition of an annual deductible on 5 30 enteral formula coverage benefits that exceeds $2,500 per year 5 31 for each family covered or an aggregate annual limit for such 5 32 benefits that is less than $12,500 per year for each family. 5 33 The bill requires that the benefits must be provided, at a 5 34 minimum, to each male insured until that individual reaches 21 5 35 years of age or ceases to be enrolled as a full=time student, 6 1 whichever occurs later, and to each female insured until that 6 2 individual reaches the age of 45. 6 3 AUDIOLOGICAL SERVICES AND HEARING AIDS FOR CHILDREN. New 6 4 Code section 514C.24 requires specified individual and group 6 5 health insurance contracts, policies, or plans that provide 6 6 coverage for third=party payment or prepayment of health or 6 7 medical expenses to provide minimum coverage for audiological 6 8 services and hearing aids for children. 6 9 The bill provides that "minimum coverage for audiological 6 10 services and hearing aids for children" must include, at a 6 11 minimum, coverage for hearing aids that are prescribed, 6 12 filled, and dispensed by a licensed audiologist for children 6 13 up to 18 years of age, coverage for an ear mold and a hearing 6 14 aid for each hearing=impaired ear payable every 24 months for 6 15 children up to 18 years of age, and coverage for up to four 6 16 additional ear molds per year for children up to three years 6 17 of age. 6 18 HUMAN PAPILLOMA VIRUS VACCINATIONS. New Code section 6 19 514C.25 requires specified individual and group health 6 20 insurance contracts, policies, or plans that provide coverage 6 21 of any vaccinations or immunizations to provide coverage of 6 22 vaccinations for the human papilloma virus to each female 6 23 insured who is nine years of age until that individual reaches 6 24 26 years of age. 6 25 The bill defines "human papilloma virus" to mean the human 6 26 papilloma virus as defined by the centers for disease control 6 27 and prevention of the United States department of health and 6 28 human services. 6 29 LSB 1631YC 82 6 30 av:rj/cf/24