HF 50 (LSB 1140YH (3) 89)

HOUSE FILE 50

BY  HEIN

A BILL FOR

An Act relating to third-party payment of insurance benefits for medically necessary food, and vitamins and individual amino acids, for certain covered conditions, and including applicability provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.36  Medically necessary food, vitamins, and individual amino acids.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense obligation imposed on a covered person by a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses.
   b.  “Covered condition” means all of the following:
   (1)  Inherited metabolic disorders including all of the following:
   (a)  A disorder classified as a metabolic disorder on the most recent United States secretary of health and human services recommended uniform screening panel core and secondary conditions list, as recommended by the United States health resources and services administration advisory committee on heritable disorders in newborns and children.
   (b)  N-acetyl glutamate synthase deficiency.
   (c)  Ornithine transcarbamylase deficiency.
   (d)  Carbamoyl phosphate synthestase deficiency.
   (e)  Inherited disorders of mitochondrial functioning.
   (2)  Medical and surgical conditions of malabsorption, including all of the following:
   (a)  Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract, including short bowel syndrome and chronic intestinal pseudo-obstruction.
   (b)  Malabsorption due to liver or pancreatic disease.
   (3)  Immunoglobulin E and non-immunoglobulin E-mediated allergies to food proteins including all of the following:
   (a)  Food protein-induced enterocolitis syndrome.
   (b)  Eosinophilic disorders, including eosinophilic esophagitis, eosinophilic gastroenteritis, eosinophilic colitis, and post-transplant eosinophilic disorders.
   (4)  Inflammatory or immune mediated conditions of the alimentary tract, including all of the following:
   (a)  Inflammatory bowel disease, including Crohn’s disease, ulcerative colitis, and indeterminate colitis.
   (b)  Gastroesophageal reflux disease that is nonresponsive to standard medical therapies.
   c.  “Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.
   d.  “Durable medical equipment” means the same as defined in 42 U.S.C. §1395x(n). 
   e.  “Health care professional” means the same as defined in section 514J.102.
   f.  “Health carrier” means the same as defined in section 514J.102.
   g.  “Low protein modified food product” means a type of food that is modified to be low in protein and formulated for oral consumption for individuals with inborn errors of protein metabolism. “Low protein modified food product” shall not include foods that are naturally low in protein. 
   h.  “Medically necessary food” means food, including a low protein modified food product, an amino acid preparation product, a modified fat preparation product, a prescription nutritional formula, or an over-the-counter nutritional formula that meets all of the following requirements:
   (1)  Is furnished pursuant to a prescription, order, or recommendation of a covered person’s health care professional for the dietary management of a covered condition.
   (2)  Is a specially formulated and processed product for the partial or exclusive feeding of an individual by means of oral intake or enteral feeding by tube. 
   (3)  Is intended for the dietary management of an individual who because of therapeutic or chronic medical needs has limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foodstuffs or certain nutrients, or who has other special medically determined nutrient requirements, the dietary management of which cannot be achieved solely by modification of a normal diet.
   (4)  Is intended to be used under medical supervision, including in a home setting.
   (5)  Is intended only for an individual receiving active and ongoing medical supervision where the individual requires medical care and instruction on the use of the food on a recurring basis.
   (6)  Is not a food that is taken as part of an overall diet designed to reduce the risk of a disease, the risk of a medical condition, or as a weight loss product, even if the food is recommended by a health care professional.
   (7)  Is not a food marketed as gluten-free for the management of celiac disease or non-celiac gluten sensitivity.
   (8)  Is not a food marketed for the management of diabetes.
   i.  “Medically necessary vitamins and individual amino acids” means vitamins and amino acids that are used for the management of a covered condition pursuant to a prescription, order, or recommendation of a covered person’s health care professional. 
   2.  a.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall provide coverage for all of the following:
   (1)  Medically necessary food and the medical equipment and supplies, not to include durable medical equipment, necessary to administer the food.
   (2)  Medically necessary vitamins and individual amino acids.
   b.  Coverage shall be a minimum of eighty percent of the cost to a covered person for medically necessary food and the medical equipment and supplies necessary to administer the food, and medically necessary vitamins and individual amino acids.
   c.  Coverage shall not be subject to cost-sharing that is greater than the cost-sharing that the policy, contract, or plan requires for other health or medical expenses covered under the policy, contract, or plan. 
   d.  Prior authorization shall not be required for coverage.
   3.  a.  This section shall apply to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  A plan established for public employees pursuant to chapter 509A.
   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.
   4.  The commissioner of insurance shall adopt rules pursuant to chapter 17A as necessary to administer this section.
    Sec. 2.  APPLICABILITY.  This Act applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2022.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to third-party payment of insurance benefits for medically necessary food, and vitamins and individual amino acids, for certain covered conditions.
   The bill defines “covered condition” as inherited metabolic disorders; medical and surgical conditions of malabsorption; immunoglobulin E and non-immunoglobulin E-mediated allergies to food proteins; and inflammatory or immune mediated conditions of the alimentary tract. The definition also includes, as detailed in the bill, specific conditions under each of the different categories of conditions. The bill also defines “medically necessary food” and “medically necessary vitamins and individual amino acids”. 
   The bill requires a health carrier that offers individual, group, or small group contracts, policies, or plans in this state that provide for third-party payment or prepayment of health or medical expenses to offer coverage for medically necessary food and the medical equipment and supplies, not to include durable medical equipment, necessary to administer the food; and for medically necessary vitamins and individual amino acids. The bill requires that the coverage be a minimum of 80 percent of the cost to a covered person for medically necessary food and the medical equipment and supplies necessary to administer the food, and medically necessary vitamins and individual amino acids. The bill prohibits the coverage from being subject to cost-sharing that is greater than the cost-sharing that the policy, contract, or plan requires for other health or medical expenses covered under the policy, contract, or plan. Prior authorization cannot be a requirement for coverage.
   The commissioner of insurance must adopt rules to administer the requirements of the bill.
   The bill applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2022, by the third-party payment providers enumerated in the bill. The bill specifies the types of specialized health-related insurance that are not subject to the bill.