Note
Article heading amended by L 2002, c 155, §48.
State innovation waiver task force; health care reform plan; reports to 2015-2017 legislature (dissolved June 30, 2017). L 2014, c 158; L 2015, c 184.
Cross References
Conformance to federal law, see §431:2-201.5.
Federally qualified health centers; rural health clinics; reimbursement, see §346-53.6.
Health maintenance organization act, see chapter 432D.
Medicaid-related mandates, see chapter 431L.
Mental health and alcohol and drug abuse treatment insurance benefits, see chapter 431M.
Patients' bill of rights and responsibilities act, see chapter 432E.
Prescription drug benefits, see chapter 431R.
Prescription drugs; mail order opt out option, see §87A-16.3.
Proposed mandatory health insurance coverage and assessment report, see §§23-51, 52.
State health insurance program, see chapter 431N.
Attorney General Opinions
Section 431:10A-601 applied to all parts of article 10A if the category of policy under consideration included family coverage, as defined in §431:10A-103. Att. Gen. Op. 97-10.
The placement of §431:10A-601 in this article, regulating content of insurance contracts, makes clear that the legislative intent was to mandate benefits that must be made available by insurers that write contracts of insurance providing family coverage. Att. Gen. Op. 97-10.
Law Journals and Reviews
Tax Justice and Same-Sex Domestic Partner Health Benefits: An Analysis of the Tax Equity For Health Plan Beneficiaries Act. 32 UH L. Rev. 73 (2009).
Case Notes
As chapter 432D does not cover the field of managed care regulation and because §§432D-2, 432E-1, and this article can be read together and there is no explicit language or policy reason not to give each statute effect, chapter 432D does not repeal chapter 432E by implication. 126 H. 326, 271 P.3d 621 (2012).
Properly licensed HMOs, like plaintiff, were authorized pursuant to §432D-1 to "provide or arrange", at their option, for the closed panel health care services required under the managed care plan program; accident and health insurers were authorized under §431:10A-205(b) to arrange for medical services for members using a defined network of providers, i.e., particular "hospitals or persons"; thus, this article and chapter 432D authorized both accident and health insurers and HMOs, as risk-bearing entities, to provide the closed panel product required by the managed care plan contracts. 126 H. 326, 271 P.3d 621 (2012).
PART I. INDIVIDUAL ACCIDENT AND HEALTH
OR SICKNESS POLICIES
Note
Part heading amended by L 2002, c 155, §48.
Attorney General Opinions
Section 431:10A-601 applied to all parts of article 10A if the category of policy under consideration included family coverage, as defined in §431:10A-103. Att. Gen. Op. 97-10.
Case Notes
Under this article and §431:10A-105(2)(A)(ii), standard "incontestability clause" of contract precluded insurer from denying insured "total disability benefit" contracted for, notwithstanding that HIV infection that caused the disability arguably "manifested" itself prior to policy's effective date of coverage. 86 H. 262, 948 P.2d 1103.
§431:10A-120 Medical foods and low-protein modified food products; treatment of inborn error of metabolism; notice. (a) Each policy of accident and health or sickness insurance, other than life insurance, disability income insurance, and long-term care insurance, issued or renewed in this State, each employer group health policy, contract, plan, or agreement issued or renewed in this State, all accident and health or sickness insurance policies issued or renewed in this State, all policies providing family coverages as defined in section 431:10A-103, and all policies providing reciprocal beneficiary family coverage as defined in section 431:10A-601, shall contain a provision for coverage for medical foods and low-protein modified food products for the treatment of an inborn error of metabolism for its policyholders or dependents of the policyholder in this State; provided that the medical food or low-protein modified food product is:
(1) Prescribed as medically necessary for the therapeutic treatment of an inborn error of metabolism; and
(2) Consumed or administered enterally under the supervision of a physician or osteopathic physician licensed under chapter 453.
Coverage shall be for at least eighty per cent of the cost of the medical food or low-protein modified food product prescribed and administered pursuant to this subsection.
(b) Every insurer shall provide notice to its policyholders regarding the coverage required by this section. The notice shall be in writing and prominently placed in any literature or correspondence sent to policyholders and shall be transmitted to policyholders during calendar year 2000 when annual information is made available to policyholders, or in any other mailing to policyholders, but in no case later than December 31, 2000.
(c) For the purposes of this section:
"Inborn error of metabolism" means a disease caused by an inherited abnormality of the body chemistry of a person that is characterized by deficient metabolism, originating from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate, or fat.
"Low-protein modified food product" means a food product that:
(1) Is specially formulated to have less than one gram of protein per serving;
(2) Is prescribed or ordered by a physician or osteopathic physician as medically necessary for the dietary treatment of an inborn error of metabolism; and
(3) Does not include a food that is naturally low in protein.
"Medical food" means a food that is formulated to be consumed or administered enterally under the supervision of a physician or osteopathic physician and is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. [L 1999, c 86, §2; am L 2002, c 155, §58; am L 2003, c 212, §76; am L 2009, c 11, §50]
Section: Previous 431-10a-116.2 431-10a-116.5 431-10a-116.6 431-10a-116.7 431-10a-117 431-10a-118 431-10a-119 431-10a-120 431-10a-121 431-10a-122 431-10a-125 431-10a-126 431-10a-131 431-10a-132 431-10a-133 NextLast modified: October 27, 2016