§2764. Coverage for medically necessary infant formula

(REALLOCATED FROM TITLE 24-A, SECTION 2763)

All individual health insurance policies, contracts and certificates must provide coverage for amino acid-based elemental infant formula for children 2 years of age and under in accordance with this section.   [RR 2007, c. 2, §11 (RAL).]

1.  Determination of medical necessity.  Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has submitted documentation that the amino acid-based elemental infant formula is medically necessary health care as defined in section 4301-A, subsection 10-A, that the amino acid-based elemental infant formula is the predominant source of nutritional intake at a rate of 50% or greater and that other commercial infant formulas, including cow milk-based and soy milk-based formulas have been tried and have failed or are contraindicated. A licensed physician may be required to confirm and document ongoing medical necessity at least annually.

[RR 2007, c. 2, §11 (RAL).]

2.  Method of delivery.  Coverage for amino acid-based elemental infant formula must be provided without regard to the method of delivery of the formula.

[RR 2007, c. 2, §11 (RAL).]

3.  Required diagnosis.  Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has diagnosed and through medical evaluation has documented one of the following conditions:

A. Symptomatic allergic colitis or proctitis;   [RR 2007, c. 2, §11 (RAL).]

B. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis;   [RR 2007, c. 2, §11 (RAL).]

C. A history of anaphylaxis;   [RR 2007, c. 2, §11 (RAL).]

D. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies;   [RR 2007, c. 2, §11 (RAL).]

E. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider;   [RR 2007, c. 2, §11 (RAL).]

F. Cystic fibrosis; or   [RR 2007, c. 2, §11 (RAL).]

G. Malabsorption of cow milk-based or soy milk-based infant formula.   [RR 2007, c. 2, §11 (RAL).]

[RR 2007, c. 2, §11 (RAL).]

4.  Health savings accounts.  Coverage for amino acid-based elemental infant formula under a health insurance policy, contract or certificate issued in connection with a health savings account as authorized under Title XII of the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003 may be subject to the same deductible and out-of-pocket limits that apply to overall benefits under the policy, contract or certificate.

[RR 2007, c. 2, §11 (RAL).]

SECTION HISTORY

RR 2007, c. 2, §11 (RAL).