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House File 50 - IntroducedA Bill ForAn Act 1relating to third-party payment of insurance benefits
2for medically necessary food, and vitamins and individual
3amino acids, for certain covered conditions, and including
4applicability provisions.
5BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 514C.36 Medically necessary food,
2vitamins, and individual amino acids.
31. As used in this section, unless the context otherwise
4requires:
5a. “Cost-sharing” means any coverage limit, copayment,
6coinsurance, deductible, or other out-of-pocket expense
7obligation imposed on a covered person by a policy, contract,
8or plan providing for third-party payment or prepayment of
9health or medical expenses.
10b. “Covered condition” means all of the following:
11(1) Inherited metabolic disorders including all of the
12following:
13(a) A disorder classified as a metabolic disorder on
14the most recent United States secretary of health and human
15services recommended uniform screening panel core and secondary
16conditions list, as recommended by the United States health
17resources and services administration advisory committee on
18heritable disorders in newborns and children.
19(b) N-acetyl glutamate synthase deficiency.
20(c) Ornithine transcarbamylase deficiency.
21(d) Carbamoyl phosphate synthestase deficiency.
22(e) Inherited disorders of mitochondrial functioning.
23(2) Medical and surgical conditions of malabsorption,
24including all of the following:
25(a) Impaired absorption of nutrients caused by disorders
26affecting the absorptive surface, functional length, and
27motility of the gastrointestinal tract, including short bowel
28syndrome and chronic intestinal pseudo-obstruction.
29(b) Malabsorption due to liver or pancreatic disease.
30(3) Immunoglobulin E and non-immunoglobulin E-mediated
31allergies to food proteins including all of the following:
32(a) Food protein-induced enterocolitis syndrome.
33(b) Eosinophilic disorders, including eosinophilic
34esophagitis, eosinophilic gastroenteritis, eosinophilic
35colitis, and post-transplant eosinophilic disorders.
-1- 1(4) Inflammatory or immune mediated conditions of the
2alimentary tract, including all of the following:
3(a) Inflammatory bowel disease, including Crohn’s disease,
4ulcerative colitis, and indeterminate colitis.
5(b) Gastroesophageal reflux disease that is nonresponsive
6to standard medical therapies.
7c. “Covered person” means a policyholder, subscriber, or
8other person participating in a policy, contract, or plan that
9provides for third-party payment or prepayment of health or
10medical expenses.
11d. “Durable medical equipment” means the same as defined in
1242 U.S.C. §1395x(n).
13e. “Health care professional” means the same as defined in
14section 514J.102.
15f. “Health carrier” means the same as defined in section
16514J.102.
17g. “Low protein modified food product” means a type of food
18that is modified to be low in protein and formulated for oral
19consumption for individuals with inborn errors of protein
20metabolism. “Low protein modified food product” shall not
21include foods that are naturally low in protein.
22h. “Medically necessary food” means food, including a low
23protein modified food product, an amino acid preparation
24product, a modified fat preparation product, a prescription
25nutritional formula, or an over-the-counter nutritional formula
26that meets all of the following requirements:
27(1) Is furnished pursuant to a prescription, order, or
28recommendation of a covered person’s health care professional
29for the dietary management of a covered condition.
30(2) Is a specially formulated and processed product for the
31partial or exclusive feeding of an individual by means of oral
32intake or enteral feeding by tube.
33(3) Is intended for the dietary management of an individual
34who because of therapeutic or chronic medical needs has limited
35or impaired capacity to ingest, digest, absorb, or metabolize
-2-1ordinary foodstuffs or certain nutrients, or who has other
2special medically determined nutrient requirements, the dietary
3management of which cannot be achieved solely by modification
4of a normal diet.
5(4) Is intended to be used under medical supervision,
6including in a home setting.
7(5) Is intended only for an individual receiving active
8and ongoing medical supervision where the individual requires
9medical care and instruction on the use of the food on a
10recurring basis.
11(6) Is not a food that is taken as part of an overall diet
12designed to reduce the risk of a disease, the risk of a medical
13condition, or as a weight loss product, even if the food is
14recommended by a health care professional.
15(7) Is not a food marketed as gluten-free for the management
16of celiac disease or non-celiac gluten sensitivity.
17(8) Is not a food marketed for the management of diabetes.
18i. “Medically necessary vitamins and individual amino acids”
19means vitamins and amino acids that are used for the management
20of a covered condition pursuant to a prescription, order, or
21recommendation of a covered person’s health care professional.
222. a. Notwithstanding the uniformity of treatment
23requirements of section 514C.6, a policy, contract, or plan
24providing for third-party payment or prepayment of health
25or medical expenses shall provide coverage for all of the
26following:
27(1) Medically necessary food and the medical equipment and
28supplies, not to include durable medical equipment, necessary
29to administer the food.
30(2) Medically necessary vitamins and individual amino
31acids.
32b. Coverage shall be a minimum of eighty percent of the
33cost to a covered person for medically necessary food and the
34medical equipment and supplies necessary to administer the
35food, and medically necessary vitamins and individual amino
-3-1acids.
2c. Coverage shall not be subject to cost-sharing that is
3greater than the cost-sharing that the policy, contract, or
4plan requires for other health or medical expenses covered
5under the policy, contract, or plan.
6d. Prior authorization shall not be required for coverage.
73. a. This section shall apply to the following classes
8of third-party payment provider contracts, policies, or plans
9delivered, issued for delivery, continued, or renewed in this
10state:
11(1) Individual or group accident and sickness insurance
12providing coverage on an expense-incurred basis.
13(2) An individual or group hospital or medical service
14contract issued pursuant to chapter 509, 514, or 514A.
15(3) An individual or group health maintenance organization
16contract regulated under chapter 514B.
17(4) A plan established for public employees pursuant to
18chapter 509A.
19b. This section shall not apply to accident-only,
20specified disease, short-term hospital or medical, hospital
21confinement indemnity, credit, dental, vision, Medicare
22supplement, long-term care, basic hospital and medical-surgical
23expense coverage as defined by the commissioner, disability
24income insurance coverage, coverage issued as a supplement
25to liability insurance, workers’ compensation or similar
26insurance, or automobile medical payment insurance.
274. The commissioner of insurance shall adopt rules pursuant
28to chapter 17A as necessary to administer this section.
29 Sec. 2. APPLICABILITY. This Act applies to third-party
30payment provider contracts, policies, or plans delivered,
31issued for delivery, continued, or renewed in this state on or
32after January 1, 2022.
33EXPLANATION
34The inclusion of this explanation does not constitute agreement with
35the explanation’s substance by the members of the general assembly.
-4- 1This bill relates to third-party payment of insurance
2benefits for medically necessary food, and vitamins and
3individual amino acids, for certain covered conditions.
4The bill defines “covered condition” as inherited metabolic
5disorders; medical and surgical conditions of malabsorption;
6immunoglobulin E and non-immunoglobulin E-mediated allergies to
7food proteins; and inflammatory or immune mediated conditions
8of the alimentary tract. The definition also includes, as
9detailed in the bill, specific conditions under each of the
10different categories of conditions. The bill also defines
11“medically necessary food” and “medically necessary vitamins
12and individual amino acids”.
13The bill requires a health carrier that offers individual,
14group, or small group contracts, policies, or plans in this
15state that provide for third-party payment or prepayment of
16health or medical expenses to offer coverage for medically
17necessary food and the medical equipment and supplies, not to
18include durable medical equipment, necessary to administer
19the food; and for medically necessary vitamins and individual
20amino acids. The bill requires that the coverage be a minimum
21of 80 percent of the cost to a covered person for medically
22necessary food and the medical equipment and supplies necessary
23to administer the food, and medically necessary vitamins and
24individual amino acids. The bill prohibits the coverage
25from being subject to cost-sharing that is greater than the
26cost-sharing that the policy, contract, or plan requires for
27other health or medical expenses covered under the policy,
28contract, or plan. Prior authorization cannot be a requirement
29for coverage.
30The commissioner of insurance must adopt rules to administer
31the requirements of the bill.
32The bill applies to third-party payment provider contracts,
33policies, or plans delivered, issued for delivery, continued,
34or renewed in this state on or after January 1, 2022, by the
35third-party payment providers enumerated in the bill. The bill
-5-1specifies the types of specialized health-related insurance
2that are not subject to the bill.
-6-ko/rn
2for medically necessary food, and vitamins and individual
3amino acids, for certain covered conditions, and including
4applicability provisions.
5BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. NEW SECTION. 514C.36 Medically necessary food,
2vitamins, and individual amino acids.
31. As used in this section, unless the context otherwise
4requires:
5a. “Cost-sharing” means any coverage limit, copayment,
6coinsurance, deductible, or other out-of-pocket expense
7obligation imposed on a covered person by a policy, contract,
8or plan providing for third-party payment or prepayment of
9health or medical expenses.
10b. “Covered condition” means all of the following:
11(1) Inherited metabolic disorders including all of the
12following:
13(a) A disorder classified as a metabolic disorder on
14the most recent United States secretary of health and human
15services recommended uniform screening panel core and secondary
16conditions list, as recommended by the United States health
17resources and services administration advisory committee on
18heritable disorders in newborns and children.
19(b) N-acetyl glutamate synthase deficiency.
20(c) Ornithine transcarbamylase deficiency.
21(d) Carbamoyl phosphate synthestase deficiency.
22(e) Inherited disorders of mitochondrial functioning.
23(2) Medical and surgical conditions of malabsorption,
24including all of the following:
25(a) Impaired absorption of nutrients caused by disorders
26affecting the absorptive surface, functional length, and
27motility of the gastrointestinal tract, including short bowel
28syndrome and chronic intestinal pseudo-obstruction.
29(b) Malabsorption due to liver or pancreatic disease.
30(3) Immunoglobulin E and non-immunoglobulin E-mediated
31allergies to food proteins including all of the following:
32(a) Food protein-induced enterocolitis syndrome.
33(b) Eosinophilic disorders, including eosinophilic
34esophagitis, eosinophilic gastroenteritis, eosinophilic
35colitis, and post-transplant eosinophilic disorders.
-1- 1(4) Inflammatory or immune mediated conditions of the
2alimentary tract, including all of the following:
3(a) Inflammatory bowel disease, including Crohn’s disease,
4ulcerative colitis, and indeterminate colitis.
5(b) Gastroesophageal reflux disease that is nonresponsive
6to standard medical therapies.
7c. “Covered person” means a policyholder, subscriber, or
8other person participating in a policy, contract, or plan that
9provides for third-party payment or prepayment of health or
10medical expenses.
11d. “Durable medical equipment” means the same as defined in
1242 U.S.C. §1395x(n).
13e. “Health care professional” means the same as defined in
14section 514J.102.
15f. “Health carrier” means the same as defined in section
16514J.102.
17g. “Low protein modified food product” means a type of food
18that is modified to be low in protein and formulated for oral
19consumption for individuals with inborn errors of protein
20metabolism. “Low protein modified food product” shall not
21include foods that are naturally low in protein.
22h. “Medically necessary food” means food, including a low
23protein modified food product, an amino acid preparation
24product, a modified fat preparation product, a prescription
25nutritional formula, or an over-the-counter nutritional formula
26that meets all of the following requirements:
27(1) Is furnished pursuant to a prescription, order, or
28recommendation of a covered person’s health care professional
29for the dietary management of a covered condition.
30(2) Is a specially formulated and processed product for the
31partial or exclusive feeding of an individual by means of oral
32intake or enteral feeding by tube.
33(3) Is intended for the dietary management of an individual
34who because of therapeutic or chronic medical needs has limited
35or impaired capacity to ingest, digest, absorb, or metabolize
-2-1ordinary foodstuffs or certain nutrients, or who has other
2special medically determined nutrient requirements, the dietary
3management of which cannot be achieved solely by modification
4of a normal diet.
5(4) Is intended to be used under medical supervision,
6including in a home setting.
7(5) Is intended only for an individual receiving active
8and ongoing medical supervision where the individual requires
9medical care and instruction on the use of the food on a
10recurring basis.
11(6) Is not a food that is taken as part of an overall diet
12designed to reduce the risk of a disease, the risk of a medical
13condition, or as a weight loss product, even if the food is
14recommended by a health care professional.
15(7) Is not a food marketed as gluten-free for the management
16of celiac disease or non-celiac gluten sensitivity.
17(8) Is not a food marketed for the management of diabetes.
18i. “Medically necessary vitamins and individual amino acids”
19means vitamins and amino acids that are used for the management
20of a covered condition pursuant to a prescription, order, or
21recommendation of a covered person’s health care professional.
222. a. Notwithstanding the uniformity of treatment
23requirements of section 514C.6, a policy, contract, or plan
24providing for third-party payment or prepayment of health
25or medical expenses shall provide coverage for all of the
26following:
27(1) Medically necessary food and the medical equipment and
28supplies, not to include durable medical equipment, necessary
29to administer the food.
30(2) Medically necessary vitamins and individual amino
31acids.
32b. Coverage shall be a minimum of eighty percent of the
33cost to a covered person for medically necessary food and the
34medical equipment and supplies necessary to administer the
35food, and medically necessary vitamins and individual amino
-3-1acids.
2c. Coverage shall not be subject to cost-sharing that is
3greater than the cost-sharing that the policy, contract, or
4plan requires for other health or medical expenses covered
5under the policy, contract, or plan.
6d. Prior authorization shall not be required for coverage.
73. a. This section shall apply to the following classes
8of third-party payment provider contracts, policies, or plans
9delivered, issued for delivery, continued, or renewed in this
10state:
11(1) Individual or group accident and sickness insurance
12providing coverage on an expense-incurred basis.
13(2) An individual or group hospital or medical service
14contract issued pursuant to chapter 509, 514, or 514A.
15(3) An individual or group health maintenance organization
16contract regulated under chapter 514B.
17(4) A plan established for public employees pursuant to
18chapter 509A.
19b. This section shall not apply to accident-only,
20specified disease, short-term hospital or medical, hospital
21confinement indemnity, credit, dental, vision, Medicare
22supplement, long-term care, basic hospital and medical-surgical
23expense coverage as defined by the commissioner, disability
24income insurance coverage, coverage issued as a supplement
25to liability insurance, workers’ compensation or similar
26insurance, or automobile medical payment insurance.
274. The commissioner of insurance shall adopt rules pursuant
28to chapter 17A as necessary to administer this section.
29 Sec. 2. APPLICABILITY. This Act applies to third-party
30payment provider contracts, policies, or plans delivered,
31issued for delivery, continued, or renewed in this state on or
32after January 1, 2022.
33EXPLANATION
34The inclusion of this explanation does not constitute agreement with
35the explanation’s substance by the members of the general assembly.
-4- 1This bill relates to third-party payment of insurance
2benefits for medically necessary food, and vitamins and
3individual amino acids, for certain covered conditions.
4The bill defines “covered condition” as inherited metabolic
5disorders; medical and surgical conditions of malabsorption;
6immunoglobulin E and non-immunoglobulin E-mediated allergies to
7food proteins; and inflammatory or immune mediated conditions
8of the alimentary tract. The definition also includes, as
9detailed in the bill, specific conditions under each of the
10different categories of conditions. The bill also defines
11“medically necessary food” and “medically necessary vitamins
12and individual amino acids”.
13The bill requires a health carrier that offers individual,
14group, or small group contracts, policies, or plans in this
15state that provide for third-party payment or prepayment of
16health or medical expenses to offer coverage for medically
17necessary food and the medical equipment and supplies, not to
18include durable medical equipment, necessary to administer
19the food; and for medically necessary vitamins and individual
20amino acids. The bill requires that the coverage be a minimum
21of 80 percent of the cost to a covered person for medically
22necessary food and the medical equipment and supplies necessary
23to administer the food, and medically necessary vitamins and
24individual amino acids. The bill prohibits the coverage
25from being subject to cost-sharing that is greater than the
26cost-sharing that the policy, contract, or plan requires for
27other health or medical expenses covered under the policy,
28contract, or plan. Prior authorization cannot be a requirement
29for coverage.
30The commissioner of insurance must adopt rules to administer
31the requirements of the bill.
32The bill applies to third-party payment provider contracts,
33policies, or plans delivered, issued for delivery, continued,
34or renewed in this state on or after January 1, 2022, by the
35third-party payment providers enumerated in the bill. The bill
-5-1specifies the types of specialized health-related insurance
2that are not subject to the bill.
-6-ko/rn