SSB 1171 (LSB 2173XC (2) 85)

SENATE FILE _____

BY  (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON McCOY)

A BILL FOR

An Act requiring every insurer offering certain individual or group health insurance policies to provide coverage for treatment of certain inborn errors of metabolism with a dietary restriction.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.30  Enteral formulas —— coverage.
   1.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy or contract providing for third-party payment or prepayment of health or medical expenses shall not exclude or restrict benefits for enteral formulas for home use for which a practitioner licensed by law to prescribe and administer prescription drugs has issued a written order, if such policy or contract provides benefits for other outpatient prescription drugs or devices. Such written order must state that the enteral formula is medically necessary for the patient.
   2.  For purposes of this section, “enteral formula” means a formula which has been proven effective for the treatment of inborn errors of metabolism with a dietary restriction, which if left untreated will cause malnourishment, chronic physical disability, mental retardation, or death. “Enteral formula” includes low-protein medical food and metabolic formula prescribed for persons diagnosed with inborn errors of metabolism with a dietary restriction. The commissioner, by rule, shall further define “enteral formula”.
   3.
  a.  This section applies to the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2013:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  Any individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  Any individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  Any other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.
   (5)  A plan established pursuant to chapter 509A for public employees.
   (6)  An organized delivery system licensed by the director of public health.
   b.  This section shall not apply to accident only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
EXPLANATION
   This bill creates new Code section 514C.30 and provides that a policy or contract providing for third-party payment or prepayment of health or medical expenses which provides coverage benefits for other outpatient prescription drugs or devices shall not exclude or restrict coverage benefits for enteral formulas for home use prescribed by a practitioner as being medically necessary and proven effective as a disease- specific treatment regimen for individuals who are or will become malnourished or suffer from disorders, which, if left untreated, will cause chronic physical disability, mental retardation, or death.
   The bill defines “enteral formula” as a formula which has been proven effective for the treatment of inborn errors of metabolism with a dietary restriction which if left untreated will cause malnourishment, chronic physical disability, mental retardation, or death. “Enteral formula” is defined to include low-protein medical food and metabolic formula prescribed for persons diagnosed with inborn errors of metabolism with a dietary restriction. The bill provides that the commissioner, by rule, shall further define “enteral formula”.
   The bill provides that the new Code section applies to third-party payment provider contracts, or policies delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2013.