S1929

An Act concerning health insurance coverage for amino acid-based elemental formula and amending P.L.1997, c.338.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. Section 1 of P.L.1997, c.338 (C.17:48-6s) is amended to read as follows:

1. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the contract provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.), or an eosinophilic disorder or short-bowel syndrome; "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; “amino acid-based elemental formula” means a product intended for the diagnosis and dietary treatment of eosinophilic disorders and short-bowel syndrome under direction of a physician; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.

The benefits shall be provided to the same extent as for any other medical condition under the contract.

The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.

(cf: P.L.1997,c.338,s.1)

2. Section 2 of P.L.1997, c.338 (C.17:48A-7q) is amended to read as follows:

2. No group or individual medical service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the contract provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

The benefits shall be provided to the same extent as for any other medical condition under the contract.

The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.

(cf: P.L.1997, c.338, s.2)

3. Section 3 of P.L.1997, c.338 (C.17:48E-35.16) is amended to read as follows:

3. No group or individual health service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the contract provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

The benefits shall be provided to the same extent as for any other medical condition under the contract.

The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.

(cf: P.L.1997, c.338, s.3)

4. Section 4 of P.L.1997, c.338 (C.17B:26-2.1o) is amended to read as follows:

4. No individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

The benefits shall be provided to the same extent as for any other medical condition under the policy.

The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

(cf: P.L.1997, c.338, s.4)

5. Section 5 of P.L.1997, c.338 (C.17B:27-46.1r) is amended to read as follows:

5. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

The benefits shall be provided to the same extent as for any other medical condition under the policy.

The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

(cf: P.L.1997, c.338, s.5)

6. Section 6 of P.L.1997, c.338 (C.17B:27A-7.4) is amended to read as follows:

6. No individual health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the health benefits plan provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

(cf: P.L.1997, c.338, s.6)

7. Section 7 of P.L.1997, c.338 (C.17B:27A-19.6) is amended to read as follows:

7. No small employer health benefits plan subject to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the health benefits plan provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

(cf: P.L.1997, c.338, s.7)

8. Section 8 of P.L.1997, c.338 (C.26:2J-4.17) is amended to read as follows:

8. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to each enrollee for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the enrollee's physician.

The health care services shall be provided to the same extent as for any other medical condition under the contract.

The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.

(cf: P.L.2012, c.17, s.269)

9. Section 9 of P.L.1997, c.338 (C.52:14-17.29c) is amended to read as follows:

9. The State Health Benefits Commission shall provide benefits to each person covered under the State Health Benefits Program for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods, amino acid-based elemental formula, and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.

The health care services shall be provided to the same extent as for any other medical condition under the program.

(cf: P.L.1997, c.338, s.9)

10. This act shall take effect immediately and shall apply to all contracts and policies issued on or after the effective date.

STATEMENT

This bill requires hospital, medical and health service corporations, individual, small employer and large group insurers, health maintenance organizations and the New Jersey State and School Employees’ Health Benefits Programs to provide coverage for amino acid-based elemental formula for the treatment of eosinophilic disorders or short-bowel syndrome.

The bill amends P.L.1997, c.338, which currently requires coverage for the therapeutic treatment of inherited metabolic diseases. Current law includes in this required coverage medical foods and low protein modified food products when diagnosed and determined to be medically necessary by the covered person's physician. The bill adds amino acid-based elemental formula.

The bill defines “amino acid-based elemental formula” to mean a product intended for the diagnosis and dietary treatment of eosinophilic disorders or short-bowel syndrome under direction of a physician. The bill also amends the definition of "inherited metabolic disease" to include an eosinophilic disorder or short-bowel syndrome.

The bill is intended to ensure coverage for amino acid-based elemental formula for the treatment of eosinophilic disorders or short-bowel syndrome. Eosinophilic esophagitis is a chronic immune system disease. It has been identified only in the past two decades, but is now considered a major cause of digestive system illness that can lead to difficulty swallowing or cause food to get caught when swallowed.

Amino acid-based elemental formulas are prepared from individual non-allergenic amino acids different from regular dairy formulas and foods, such as milk or soy based. Amino acid-based elemental formulas are made of proteins broken down to their "elemental level" making them easily absorbed and digested by the body.