SPONSOR:

Rep. Cathcart;

Reps. Buckworth, Caulk, B. Ennis, Fallon, Hudson, Wagner; Sens. Connor, Henry, Sorenson

HOUSE OF REPRESENTATIVES

142nd GENERAL ASSEMBLY

HOUSE BILL NO. 179

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO PRECRIPTION MEDICATION.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE:

Section 1. Amend Chapter 33, Title 18 of the Delaware Code, by adding thereto a new section as follows:

"§ 3352. Coverage for prescription supplements for children 3 years and younger.

    1. This section applies to every policy or contract of health insurance, including each policy or contract issued by a health service corporation, which is delivered or issued for delivery in this State.

    2. Every policy or contract of health insurance described in subsection (a) of this section shall provide coverage for any medical foods, low-protein modified food products, and nutritional supplements prescribed by a doctor, for any covered dependant child who is 3 years of age or younger, as medically necessary for the therapeutic treatment of any allergy, allergic reaction, metabolic or enzymatic disorders, (including diseases of amino acid, organic acid, carbohydrate, or fat metabolism), or malabsorption originating from congenital defects present at birth or acquired during the neonatal period. The coverage required pursuant to this subsection includes coverage for prescription and nonprescription (‘over-the-counter’) enteral formulas for home use and shall in an amount sufficient to cover at least 80% of the cost of the prescribed medical food, low-protein modified food product, and/or nutritional supplement, not to exceed $2,500 annually for any individual covered dependant child 3 years of age or younger.

    3. The coverage required by this section shall include coverage of medically necessary services associated with administration of the prescribed medical food, low-protein modified food product, and/or nutritional supplement.

    4. This section does not require coverage for:

    1. Medical foods, low-protein modified food products, and/or nutritional supplements that may be obtained without a physician's prescription; or

    2. Any disease, condition, service or treatment that is excluded from coverage under the policy.

    1. Nothing in this section shall prevent the operation of policy provisions involving deductibles, coinsurance, allowable charge limitations, maximum dollar policy limitations or coordination of benefits."

SYNOPSIS

This Act provides for insurance coverage of medical foods, low-protein modified food products, and/or nutritional supplements for covered dependant children age 3 years and under.

Pursuant to this Act, any policy or contract of health insurance, including each policy or contract issued by a health service corporation, which is delivered or issued for delivery in this State shall provide for such coverage if such medical foods, low-protein modified food products, and/or nutritional supplements are determined by the prescribing doctor to be medically necessary for the therapeutic treatment of any allergy, allergic reaction, metabolic or enzymatic disorders, (including diseases of amino acid, organic acid, carbohydrate, or fat metabolism), or malabsorption originating from congenital defects present at birth or acquired during the neonatal period.

A cap of 80% of the total costs and $2,500 per year is placed on coverage for any individual child and nothing in this Act prevents the operation of policy provisions involving deductibles, coinsurance, allowable charge limitations, maximum dollar policy limitations or coordination of benefits.

This Act specifically does not cover medical foods, low-protein modified food products, and/or nutritional supplements that may be obtained without a physician's prescription, or any disease, condition, service or treatment that is excluded from coverage under the policy.