Amendment #6 to H4012

Providing for certain health insurance coverage

Mr. Garballey of Arlington moves to amend the bill by adding the following section:

"SECTION  XXXX.  Section 17A of chapter 32A of the General Laws, as appearing in the 2016 Official Edition, is hereby amended by striking out the first sentence and inserting in place thereof the following 4 sentences:-

The commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage for the cost of enteral formulas for home use, whether administered orally or via tube feeding, for which a physician has issued a written order. Such written order shall state that the enteral formula is clearly medically necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic physical or intellectual disability or death. Specific diseases for which enteral formulas have been proven effective shall include, but are not limited to, inherited diseases of amino acid or organic acid metabolism; eosinophilic gastrointestinal disorders; Crohn's Disease; gastroesophageal reflux with failure to thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; and multiple, severe food allergies, which if left untreated will cause malnourishment, chronic physical or intellectual disability or death. Enteral formulas which are medically necessary and taken under written order from a physician for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively.

SECTION 2. Section 47I of chapter 175 of the General Laws, as so appearing, is hereby amended by striking out the first sentence and inserting in place thereof the following 4 sentences:-

Any individual policy of accident and sickness insurance issued pursuant to section 108, and any group blanket policy of accident and sickness insurance issued pursuant to section 110, shall provide coverage for the cost of enteral formulas for home use, whether administered orally or via tube feeding, for which a physician has issued a written order. Such written order shall state that the enteral formula is clearly medically necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic physical or intellectual disability or death. Specific diseases for which enteral formulas have been proven effective shall include, but are not limited to, inherited diseases of amino acid or organic acid metabolism; eosinophilic gastrointestinal disorders;  Crohn's Disease; gastroesophageal reflux with failure to thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; and multiple, severe food allergies, which if left untreated will cause malnourishment, chronic physical or intellectual disability or death. Enteral formulas which are medically necessary and taken under written order from a physician for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively.

SECTION 3. Section 8L of chapter 176A of the General Laws, as so appearing, is hereby amended by striking out the first sentence and inserting in place thereof the following 4 sentences:-

Any contract between a subscriber and the corporation under an individual or group hospital service plan that shall be delivered, issued or renewed in the commonwealth shall provide, as benefits to all individual subscribers and members within the commonwealth, coverage for the cost of enteral formulas for home use, whether administered orally or via tube feeding, for which a physician has issued a written order. Such written order shall state that the enteral formula is clearly medically necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic physical or intellectual disability or death. Specific diseases for which enteral formulas have been proven effective shall include, but are not limited to, inherited diseases of amino acid or organic acid metabolism; eosinophilic gastrointestinal disorders; Crohn's Disease; gastroesophageal reflux with failure to thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; and multiple, severe food allergies, which if left untreated will cause malnourishment, chronic physical or intellectual disability or death. Enteral formulas which are medically necessary and taken under written order from a physician for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively.

SECTION 4. Section 4K of chapter 176B of the General Laws, as so appearing, is hereby amended by striking out the first sentence and inserting in place thereof the following 4 sentences:-

Any subscription certificate under an individual or group medical service agreement that shall be delivered, issued or renewed in the commonwealth shall provide, as benefits to all individual subscribers and members within the commonwealth, all group members having a principal place of employment within the commonwealth and all persons included in section 4C, coverage for the cost of enteral formulas for home use, whether administered orally or via tube feeding, for which a physician has issued a written order. Such written order shall state that the enteral formula is clearly medically necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic physical or intellectual disability or death. Specific diseases for which enteral formulas have been proven effective shall include, but are not limited to, inherited diseases of amino acid or organic acid metabolism; eosinophilic gastrointestinal disorders; Crohn's Disease; gastroesophageal reflux with failure to thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; and multiple, severe food allergies, which if left untreated will cause malnourishment, chronic physical or intellectual disability or death. Enteral formulas which are medically necessary and taken under written order from a physician for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively.

SECTION 5. Section 4D of chapter 176G of the General Laws, as so appearing, is hereby amended by striking out the first sentence and inserting in place thereof the following 4 sentences:-

A group health maintenance contract shall provide coverage for the cost of enteral formulas for home use, whether administered orally or via tube feeding, for which a physician has issued a written order. Such written order shall state that the enteral formula is clearly medically necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic physical or intellectual disability or death. Specific diseases for which enteral formulas have been proven effective shall include, but are not limited to, inherited diseases of amino acid or organic acid metabolism; eosinophilic gastrointestinal disorders; Crohn's Disease; gastroesophageal reflux with failure to thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; and multiple, severe food allergies, which if left untreated will cause malnourishment, chronic physical or intellectual disability or death. Enteral formulas which are medically necessary and taken under written order from a physician for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively.”