Maine Revised Statutes Title 24-A Sec. 4256 – Coverage for medically necessary infant formula
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(REALLOCATED FROM TITLE 24-A, SECTION 4254)
(REALLOCATED FROM TITLE 24-A, SECTION 4254)
All individual and group health maintenance organization 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. [PL 2007, c. 695, Pt. C, §16 (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.
[PL 2007, c. 695, Pt. C, §16 (RAL).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4256
- Contract: A legal written agreement that becomes binding when signed.
- Deductible: means the amount an enrollee is responsible to pay out of pocket before a health maintenance organization begins to pay the costs associated with treatment. See Maine Revised Statutes Title 24-A Sec. 4202-A
- health insurance: means insurance of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto, including provision for the mental and emotional welfare of human beings by defraying the costs of legal services only to the extent provided for in chapter 38. See Maine Revised Statutes Title 24-A Sec. 704
- Health maintenance organization: means a public or private organization that is organized under the laws of the Federal Government, this State, another state or the District of Columbia or a component of such an organization, and that:
A. See Maine Revised Statutes Title 24-A Sec. 4202-AInfant: means a person who has not attained the age of 18 years. See Maine Revised Statutes Title 1 Sec. 72 Provider: means a physician, hospital or person that is licensed or otherwise authorized in this State to furnish health care services. See Maine Revised Statutes Title 24-A Sec. 4202-A
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.
[PL 2007, c. 695, Pt. C, §16 (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; [PL 2007, c. 695, Pt. C, §16 (RAL).]
B. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis; [PL 2007, c. 695, Pt. C, §16 (RAL).]
C. A history of anaphylaxis; [PL 2007, c. 695, Pt. C, §16 (RAL).]
D. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies; [PL 2007, c. 695, Pt. C, §16 (RAL).]
E. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider; [PL 2007, c. 695, Pt. C, §16 (RAL).]
F. Cystic fibrosis; or [PL 2007, c. 695, Pt. C, §16 (RAL).]
G. Malabsorption of cow milk-based or soy milk-based infant formula. [PL 2007, c. 695, Pt. C, §16 (RAL).]
[PL 2007, c. 695, Pt. C, §16 (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.
[PL 2007, c. 695, Pt. C, §16 (RAL).]
SECTION HISTORY
PL 2007, c. 695, Pt. C, §16 (RAL).