HOUSE BILL 480

51st legislature - STATE OF NEW MEXICO - first session, 2013

INTRODUCED BY

Stephanie Garcia Richard

AN ACT

RELATING TO HEALTH INSURANCE; UPDATING AND CLARIFYING COVERAGE FOR MEDICALLY NECESSARY NUTRITIONAL MANAGEMENT AND SPECIAL MEDICAL FOODS FOR GENETIC INBORN ERRORS OF METABOLISM.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

     SECTION 1. Section 59A-22-41.1 NMSA 1978 (being Laws 2003, Chapter 192, Section 1) is amended to read:

     "59A-22-41.1. COVERAGE FOR MEDICAL DIETS FOR GENETIC INBORN ERRORS OF METABOLISM.--

          A. As of July 1, 2003, each individual and group health insurance policy, health care plan, certificate of health insurance and managed health care plan delivered, issued for delivery, renewed, extended or modified in this state shall provide coverage for the treatment of genetic inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism [and for which medically standard methods of diagnosis, treatment and monitoring exist] if a licensed physician issues a written order stating that the use of an amino-acid-based elemental formula is medically necessary.

          B. Coverage shall include expenses of diagnosing, monitoring and controlling disorders by nutritional and medical assessment, including clinical services, biochemical analysis, medical supplies, prescription drugs, corrective lenses for conditions related to the genetic inborn error of metabolism, nutritional management and special medical foods used in treatment to compensate for the metabolic abnormality and to maintain adequate nutritional status.

          C. Services, medical supplies, prescription drugs, corrective lenses and special medical foods required to be covered pursuant to this section are subject to the terms and conditions of the applicable individual or group policy or plan that establishes durational limits, dollar limits, deductibles and co-payments as long as the terms are not less favorable than for physical illness generally. Cost sharing for special medical foods shall be equivalent to cost sharing for daily prescription medication dispensed in a one-month supply and in no event shall cost sharing be imposed on a per-meal or per-day basis.

          D. As used in this section:

                (1) "genetic inborn error of metabolism" means a rare inherited disorder that:

                     (a) is present at birth;

                     (b) if untreated, results in mental

retardation or death; and

                     (c) causes the necessity for consumption of special medical foods;

                (2) "special medical foods" means nutritional substances in any form that are:

                     (a) formulated to be consumed or administered internally under the supervision of a physician;

                     (b) specifically processed or formulated to be distinct in one or more nutrients present in natural food;

                     (c) intended for the medical and nutritional management of patients with limited capacity to metabolize ordinary foodstuffs or certain nutrients contained in ordinary foodstuffs or who have other specific nutrient requirements as established by medical evaluation; and

                     (d) essential to optimize growth, health and metabolic homeostasis; and

                (3) "treatment" means medical services provided by licensed health care professionals, including physicians, dieticians and nutritionists [with specific training in managing patients diagnosed with genetic inborn errors of metabolism]."