Chapter 253
2008 -- H 7441
AS AMENDED
Enacted 07/05/08
A N A C T
RELATING
TO INSURANCE -- ENTERAL NUTRITION PRODUCTS
Introduced
By: Representatives DeSimone, Slater, Singleton, and Giannini
Date
Introduced: February 13, 2008
It is enacted by the General Assembly as
follows:
SECTION 1. Chapter
27-18 of the General Laws entitled "Accident and Sickness
Insurance Policies" is hereby amended by
adding thereto the following section:
27-18 -70.
Enteral nutrition products. – (a) Every individual or group health
insurance
contract, or every individual or group hospital
or medical expense insurance policy, plan, or
group policy delivered, issued for delivery, or renewed
in this state on or after January 1, 2009,
shall provide coverage for nonprescription
enteral formulas for home use for which a physician
has issued a written order and which are
medically necessary for the treatment of malabsorption
caused by Crohn’s disease, ulcerative colitis,
gastroesophageal reflux, chronic intestinal pseudo-
obstruction, and inherited diseases of amino
acids and organic acids. Coverage for inherited
diseases of amino acids and organic acids shall
include food products modified to be low protein.
Provided, however, that coverage shall not
exceed an amount of two thousand five hundred
dollars ($2,500) per covered member per year.
(b) Benefit
plans offered by an insurer may impose a copayment and/or deductibles for
the benefits mandated by this section, however,
in no instance shall the copayment or deductible
amount be greater than the copayment or
deductible amount imposed for prescription enteral
formulas or nutritional aids. Benefits for
services under this chapter shall be reimbursed in
accordance with the respective principles and
mechanisms of reimbursement for each insurer,
hospital, or medical service corporation, or
health maintenance organization. Reimbursement
shall be provided according to the respective
principles and policies of the accident and sickness
insurer. Nothing contained in this section
precludes the accident and sickness insurer from
conducting managed care, medical necessity, or
utilization review.
(c) This
section shall not apply to insurance coverage providing benefits for: (1)
hospital
confinement indemnity; (2) disability income;
(3) accident only; (4) long-term care; (5) Medicare
supplement; (6) limited benefit health; (7)
specified disease indemnity; (8) sickness or bodily
injury or death by accident or both; and (9)
other limited benefit policies.
SECTION 2. Chapter
27-19 of the General Laws entitled "Nonprofit Hospital Service
Corporations" is hereby amended by adding
thereto the following section:
27-19-61.
Enteral nutrition products. – (a) Every individual or group health
insurance
contract, or every individual or group hospital
or medical expense insurance policy, plan, or
group policy delivered, issued for delivery, or renewed
in this state on or after January 1, 2009,
shall provide coverage for nonprescription
enteral formulas for home use for which a physician
has issued a written order and which are
medically necessary for the treatment of malabsorption
caused by Crohn’s disease, ulcerative colitis,
gastroespphageal reflux, chronic intestinal pseudo-
obstruction, and inherited diseases of amino
acids and organic acids. Coverage for inherited
diseases of amino acids and organic acids shall
include food products modified to be low protein.
Provided, however, that coverage shall not
exceed an amount of two thousand five hundred
dollars ($2,500) per covered member per year.
(b) Benefit
plans offered by a hospital service corporation may impose a copayment
and/or deductible for the benefits mandated by
this section, however, in no instance shall the
copayment or deductible amount be greater than
the copayment or deductible amount imposed for
prescription enteral formulas or nutritional
aids. Benefits for services under this chapter shall be
reimbursed in accordance with the respective
principles and mechanisms of reimbursement for
each insurer, hospital, or medical service
corporation, or health maintenance organization.
Reimbursement shall be provided according to the
respective principles and policies of the
accident and sickness insurer. Nothing contained
in this section precludes the accident and
sickness insurer from conducting managed care,
medical necessity, or utilization review.
(c) This
section shall not apply to insurance coverage providing benefits for: (1)
hospital
confinement indemnity; (2) disability income;
(3) accident only; (4) long-term care; (5) Medicare
supplement; (6) limited benefit health; (7)
specified disease indemnity; (8) sickness or bodily
injury or death by accident or both; and (9)
other limited benefit policies.
SECTION 3. Chapter
27-20 of the General Laws entitled "Nonprofit Medical Service
Corporations" is hereby amended by adding
thereto the following section:
27-20-56.
Enteral nutrition products. -- (a) Every individual or group health
insurance
contract, or every individual or group hospital
or medical expense insurance policy, plan, or
group policy delivered, issued for delivery, or
renewed in this state on or after January 1, 2009,
shall provide coverage for nonprescription
enteral formulas for home use for which a physician
has issued a written order and which are
medically necessary for the treatment of malabsorption
caused by Crohn’s disease, ulcerative colitis,
gastroespphageal reflux, chronic intestinal pseudo-
obstruction, and inherited diseases of amino
acids and organic acids. Coverage for inherited
diseases of amino acids and organic acids shall
include food products modified to be low protein.
Provided, however, that coverage shall not
exceed an amount of two thousand five hundred
dollars ($2,500) per covered member per year.
(b) Benefit
plans offered by a medical service corporation may impose a copayment
and/or deductible for the benefits mandated by
this section, however, in no instance shall the
copayment or deductible amount be greater than
the copayment of deductible amount imposed for
prescription enteral formulas or nutritional
aids. Benefits for services under this chapter shall be
reimbursed in accordance with the respective
principles and mechanisms of reimbursement for
each insurer, hospital, or medical service
corporation, or health maintenance organization.
Reimbursement shall be provided according to the
respective principles and policies of the
accident and sickness insurer. Nothing contained
in this section precludes the accident and
sickness insurer from conducting managed care,
medical necessity, or utilization review.
(c) This
section shall not apply to insurance coverage providing benefits for: (1)
hospital
confinement indemnity; (2) disability income;
(3) accident only; (4) long-term care; (5) Medicare
supplement; (6) limited benefit health; (7)
specified disease indemnity; (8) sickness or bodily
injury or death by accident or both; and (9)
other limited benefit policies.
SECTION 4. Chapter
27-41 of the General Laws entitled "Health Maintenance
Organizations" is hereby amended by adding thereto
the following section:
27-41-74.
Enteral nutrition products. -- (a) Every individual or group health
insurance
contract, or every individual or group hospital
or medical expense insurance policy, plan, or
group policy delivered, issued for delivery, or
renewed in this state on or after January 1, 2009,
shall provide coverage for nonprescription
enteral formulas for home use for which a physician
has issued a written order and which are
medically necessary for the treatment of malabsorption
caused by Crohn’s disease, ulcerative colitis,
gastroespphageal reflux, chronic intestinal pseudo-
obstruction, and inherited diseases of amino
acids and organic acids. Coverage for inherited
diseases of amino acids and organic acids shall
include food products modified to be low protein.
Provided, however, that coverage shall not
exceed an amount of two thousand five hundred
dollars ($2,500) per covered member per year.
(b) Benefit
plans offered by a health maintenance organization may impose a copayment
and/or deductible for the benefits mandated by
this section, however, in no instance shall the
copayment or deductible amount be greater than
the copayment of deductible amount imposed for
prescription enteral formulas or nutritional
aids. Benefits for services under this chapter shall be
reimbursed in accordance with the respective
principles and mechanisms of reimbursement for
each insurer, hospital, or medical service
corporation, or health maintenance organization.
Reimbursement shall be provided according to the
respective principles and policies of the
accident and sickness insurer. Nothing contained
in this section precludes the accident and
sickness insurer from conducting managed care,
medical necessity, or utilization review.
(c) This
section shall not apply to insurance coverage providing benefits for: (1)
hospital
confinement indemnity; (2) disability income;
(3) accident only; (4) long-term care; (5) Medicare
supplement; (6) limited benefit health; (7)
specified disease indemnity; (8) sickness or bodily
injury or death by accident or both; and (9)
other limited benefit policies.
SECTION 5. Chapter
40-6 of the General Laws entitled "Public Assistance Act" is
hereby amended by adding thereto the following
section:
40-6-3.12.
Enteral nutrition products. – (a) As used in this section:
(1)
"Enteral nutrition" means a supplemental feeding that is provided via
the
gastrointestinal tract by mouth (orally), or
through a tube, catheter, or stoma that delivers
nutrients distal to the oral cavity.
(2)
"Nutritional risk" means actual or potential for developing
malnutrition, as evidenced
by clinical indicators, the presence of chronic
disease, or increased metabolic requirements due to
impaired ability to ingest or absorb food
adequately.
(b) The
department shall provide for vendor payment of enteral nutrition products in
accordance with rules and regulations of the
department, when determined to be medically
necessary on an individual, case-by-case basis
and ordered by a physician in accordance with
Rhode Island department of health form(s) on
enteral nutrition products. Provided, however, that
coverage shall not exceed an amount of two
thousand five hundred dollars ($2,500) per individual
per year.
(c) The
determination of medical necessity for enteral nutrition products shall be
based
upon a combination of clinical data and the
presence of indicators that would affect the relative
risks and benefits of the products including,
but not limited to:
(1) Enteral
nutrition, whether orally or by tube feeding, is used as a therapeutic regimen
to prevent serious disability or death in a
person with a medically diagnosed condition that
precludes the full use of regular food.
(2) The person
presents clinical signs and symptoms of impaired digestion malabsorption,
or nutritional risk, as indicated by the
following anthropometric measures:
(i) Weight loss
that presents actual or potential for developing, malnutrition as follows:
(A) In adults,
showing involuntary or acute weight loss of greater than or equal to ten
percent (10%) of usual body weight during a
three (3) to six (6) month period, or body mass
index (bmi) below 18.5 kg/m2;
(B) In
neonates, infants and children, showing:
(I) Very low
birth weight (lbw) even in the absence of gastrointestinal, pulmonary or
cardiac disorders;
(II) A lack of
weight gain, or weight gain less than two (2) standard deviations below the
age appropriate mean in a one month period for
children under six (6) months, or two (2) month
period for children aged six (6) to twelve (12)
months;
(III) No weight
gain or abnormally slow rate of gain for three (3) months for children
older than one year, or documented weight loss
that does not reverse promptly with instruction in
appropriate diet for age; or
(IV) Weight for
height less than the tenth (10th) percentile; and
(ii) Abnormal laboratory
test pertinent to the diagnosis.
(3) The risk
factors for actual or potential malnutrition have been identified and
documented. Such risk factors include, but are
not limited to, the following:
(i) Anatomic
structures of the gastrointestinal tract that impair digestion and absorption;
(ii)
Neurological disorders that impair swallowing or chewing;
(iii) Diagnosis
of inborn errors of metabolism that require medically necessary formula
used for specific metabolic conditions and food
products modified low in protein (for example,
phenylketonuria (pku) tyrosinemia,
homocystinuria, maple syrup urine disease, propionic aciduria
and methylmalonic aciduria);
(iv) Prolonged
nutrient losses due to malabsorption syndromes or short-bowel
syndromes, diabetes, celiac disease, chronic
pancreatitis, renal dialysis, draining abscess or
wounds, etc.;
(v) Treatment
with anti-nutrient or catabolic properties (for example, anti-tumor
treatments, corticosteroids, immunosuppressant,
etc.);
(vi) Increased
metabolic and/or caloric needs due to excessive burns, infection, trauma,
prolonged fever, hyperthyroidism, or illnesses
that impair caloric intake and/or retention; or
(vii) A
failure-to-thrive diagnosis that increases caloric needs while impairing
caloric
intake and/or retention.
(4) A
comprehensive medical history and a physical examination have been conducted to
detect factors contributing to nutritional risk.
(5) Enteral
nutrition is indicated as the primary source of nutritional support essential
for
the management of risk factors that impair
digestion or malabsorption, and for the management of
surgical preparation or postoperative care.
(6) A written
plan of care has been developed for regular monitoring of signs and
symptoms to detect improvement in the person's
condition. Nutritional status should be
monitored regularly;
(i) For
improvements in anthropometric measures;
(ii) For
improvements in laboratory test indicators; and
(iii) In
children, to assess growth and weight for height.
(d) Enteral
nutrition products shall not be considered medically necessary under certain
circumstances including, but not limited to, the
following:
(1) A medical
history and physical examination have been performed and other possible
alternatives have been identified to minimize
nutritional risk.
(2) The person
is underweight, but has the ability to meet nutritional needs through the
use of regular food consumption.
(3) Enteral
products are used as supplements to a normal or regular diet in a person
showing no clinical indicators of nutritional
risk.
(4) The person
has food allergies, lactose intolerance or dental problems, but has the
ability to meet his or her nutritional requirements
through an alternative food source.
(5) Enteral
products are to be used for dieting or a weight-loss program.
(6) No medical
history or physical examination has been taken and there is no
documentation that supports the need for enteral
nutrition products.
SECTION
6. This act shall take effect upon passage.
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LC00983/3
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