Senate Study Bill 1171 - Introduced SENATE FILE _____ BY (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON McCOY) A BILL FOR An Act requiring every insurer offering certain individual or 1 group health insurance policies to provide coverage for 2 treatment of certain inborn errors of metabolism with a 3 dietary restriction. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 TLSB 2173XC (2) 85 av/nh

S.F. _____ Section 1. NEW SECTION . 514C.30 Enteral formulas —— 1 coverage. 2 1. Notwithstanding the uniformity of treatment requirements 3 of section 514C.6, a policy or contract providing for 4 third-party payment or prepayment of health or medical expenses 5 shall not exclude or restrict benefits for enteral formulas for 6 home use for which a practitioner licensed by law to prescribe 7 and administer prescription drugs has issued a written 8 order, if such policy or contract provides benefits for other 9 outpatient prescription drugs or devices. Such written order 10 must state that the enteral formula is medically necessary for 11 the patient. 12 2. For purposes of this section, “enteral formula” means 13 a formula which has been proven effective for the treatment 14 of inborn errors of metabolism with a dietary restriction, 15 which if left untreated will cause malnourishment, chronic 16 physical disability, mental retardation, or death. “Enteral 17 formula” includes low-protein medical food and metabolic 18 formula prescribed for persons diagnosed with inborn errors of 19 metabolism with a dietary restriction. The commissioner, by 20 rule, shall further define “enteral formula” . 21 3. a. This section applies to the following classes of 22 third-party payment provider contracts or policies delivered, 23 issued for delivery, continued, or renewed in this state on or 24 after July 1, 2013: 25 (1) Individual or group accident and sickness insurance 26 providing coverage on an expense-incurred basis. 27 (2) Any individual or group hospital or medical service 28 contract issued pursuant to chapter 509, 514, or 514A. 29 (3) Any individual or group health maintenance organization 30 contract regulated under chapter 514B. 31 (4) Any other entity engaged in the business of insurance, 32 risk transfer, or risk retention, which is subject to the 33 jurisdiction of the commissioner. 34 (5) A plan established pursuant to chapter 509A for public 35 -1- LSB 2173XC (2) 85 av/nh 1/ 3

S.F. _____ employees. 1 (6) An organized delivery system licensed by the director 2 of public health. 3 b. This section shall not apply to accident only, 4 specified disease, short-term hospital or medical, hospital 5 confinement indemnity, credit, dental, vision, Medicare 6 supplement, long-term care, basic hospital and medical-surgical 7 expense coverage as defined by the commissioner, disability 8 income insurance coverage, coverage issued as a supplement 9 to liability insurance, workers’ compensation or similar 10 insurance, or automobile medical payment insurance. 11 EXPLANATION 12 This bill creates new Code section 514C.30 and provides 13 that a policy or contract providing for third-party payment 14 or prepayment of health or medical expenses which provides 15 coverage benefits for other outpatient prescription drugs or 16 devices shall not exclude or restrict coverage benefits for 17 enteral formulas for home use prescribed by a practitioner as 18 being medically necessary and proven effective as a disease- 19 specific treatment regimen for individuals who are or will 20 become malnourished or suffer from disorders, which, if left 21 untreated, will cause chronic physical disability, mental 22 retardation, or death. 23 The bill defines “enteral formula” as a formula which has 24 been proven effective for the treatment of inborn errors of 25 metabolism with a dietary restriction which if left untreated 26 will cause malnourishment, chronic physical disability, mental 27 retardation, or death. “Enteral formula” is defined to include 28 low-protein medical food and metabolic formula prescribed for 29 persons diagnosed with inborn errors of metabolism with a 30 dietary restriction. The bill provides that the commissioner, 31 by rule, shall further define “enteral formula”. 32 The bill provides that the new Code section applies to 33 third-party payment provider contracts, or policies delivered, 34 issued for delivery, continued, or renewed in this state on or 35 -2- LSB 2173XC (2) 85 av/nh 2/ 3