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HB2520 - 572R - I Ver
REFERENCE TITLE:
contraception; cost sharing prohibition
State of Arizona
House of Representatives
Fifty-seventh Legislature
Second Regular Session
2026
HB 2520
Introduced by
Representatives
Stahl Hamilton: Contreras P, Garcia, Gutierrez, Luna-N�jera, Simacek,
Travers, Villegas;� Senator Ortiz
AN
ACT
amending sections 20-826 and 20-1057.08,
Arizona Revised Statutes; amending title 20, chapter 6, article 4, Arizona
Revised Statutes, by adding section 20-1376.11; amending sections 20-1402
and 20-1404, Arizona Revised Statutes; relating to health insurance.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Section 20-826, Arizona Revised
Statutes, is amended to read:
START_STATUTE
20-826.
Subscription contracts; definitions
A. A contract between a corporation and its
subscribers shall not be issued unless the form of such contract is approved in
writing by the director.
B. Each contract shall plainly state the services to
which the subscriber is entitled and those to which the subscriber is not
entitled under the plan, and shall constitute a direct obligation of the
providers of services with which the corporation has contracted for hospital,
medical, dental or optometric services.
C. Each contract, except for dental services or
optometric services, shall be so written that the corporation shall pay
benefits for each of the following:
1. Performance of any surgical service that is
covered by the terms of such contract, regardless of the place of service.
2. Any home health services that are performed by a
licensed home health agency and that a physician has prescribed in lieu of
hospital services, as defined by the director, providing the hospital services
would have been covered.
3. Any diagnostic service that a physician has
performed outside a hospital in lieu of inpatient service, providing the
inpatient service would have been covered.
4. Any service performed in a hospital's outpatient
department or in a freestanding surgical facility, if such service would have
been covered if performed as an inpatient service.
D. Each contract for dental or optometric services
shall be so written that the corporation shall pay benefits for contracted
dental or optometric services provided by dentists or optometrists.
E. Any contract, except accidental death and
dismemberment, applied for that provides family coverage, as to such coverage
of family members, shall also provide that the benefits applicable for children
shall be payable with respect to a newly born child of the insured from the
instant of such child's birth, to a child adopted by the insured, regardless of
the age at which the child was adopted, and to a child who has been placed for
adoption with the insured and for whom the application and approval procedures
for adoption pursuant to section 8-105 or 8-108 have been completed
to the same extent that such coverage applies to other members of the
family. The coverage for newly born or adopted children or children
placed for adoption shall include coverage of injury or sickness, including
necessary care and treatment of medically diagnosed congenital defects and
birth abnormalities. If payment of a specific premium is required to
provide coverage for a child, the contract may require that notification of birth,
adoption or adoption placement of the child and payment of the required premium
must be furnished to the insurer within thirty-one days after the date of
birth, adoption or adoption placement in order to have the coverage continue
beyond the thirty-one day period.
F. Each contract that is delivered or issued for
delivery in this state after December 25, 1977 and that provides that coverage
of a dependent child shall terminate on attainment of the limiting age for
dependent children specified in the contract shall also provide in substance
that attainment of such limiting age shall not operate to terminate the
coverage of such child while the child is and continues to be both incapable of
self-sustaining employment by reason of intellectual disability or
physical disability and chiefly dependent on the subscriber for support and
maintenance. Proof of such incapacity and dependency shall be
furnished to the corporation by the subscriber within thirty-one days of
the child's attainment of the limiting age and subsequently as may be required
by the corporation, but not more frequently than annually after the two-year
period following the child's attainment of the limiting age.
G. A corporation may not cancel or refuse to renew
any subscriber's contract without giving notice of such cancellation or
nonrenewal to the subscriber under such contract. A notice by the
corporation to the subscriber of cancellation or nonrenewal of a subscription
contract shall be mailed to the named subscriber at least forty-five days
before the effective date of such cancellation or nonrenewal. The
notice shall include or be accompanied by a statement in writing of the reasons
for such action by the corporation.� Failure of the corporation to comply with
this subsection shall invalidate any cancellation or nonrenewal except a
cancellation or nonrenewal for nonpayment of premium.
H. A contract that provides coverage for surgical
services for a mastectomy shall also provide coverage incidental to the
patient's covered mastectomy for surgical services for reconstruction of the
breast on which the mastectomy was performed, surgery and reconstruction of the
other breast to produce a symmetrical appearance, prostheses, treatment of
physical complications for all stages of the mastectomy, including lymphedemas,
and at least two external postoperative prostheses subject to all of the terms
and conditions of the policy.
I. A contract that provides coverage for surgical
services for a mastectomy shall also provide coverage for preventive
mammography screening and diagnostic imaging performed on dedicated equipment
for diagnostic purposes on referral by a patient's physician, subject to all of
the terms and conditions of the policy, including:
1. A mammogram.
2. Digital breast
tomosynthesis, magnetic resonance imaging, ultrasound or other modality and at
such age and intervals as recommended by the national comprehensive cancer
network.� This includes patients at risk for breast cancer who have a family
history with one or more first or second degree relatives with breast cancer,
prior diagnosis of breast cancer, positive testing for hereditary gene
mutations or heterogeneously or dense breast tissue based on the breast imaging
reporting and data system of the American college of radiology.
J. Any contract that is issued to the insured and
that provides coverage for maternity benefits shall also provide that the
maternity benefits apply to the costs of the birth of any child legally adopted
by the insured if all of the following are true:
1. The child is adopted within one year of birth.
2. The insured is legally obligated to pay the costs
of birth.
3. All preexisting conditions and other limitations
have been met by the insured.
4. The insured has notified the insurer of the
insured's acceptability to adopt children pursuant to section 8-105,
within sixty days after such approval or within sixty days after a change in
insurance policies, plans or companies.
K. The coverage prescribed by subsection J of this
section is excess to any other coverage the natural mother may have for
maternity benefits except coverage made available to persons pursuant to title
36, chapter 29. If such other coverage exists, the agency, attorney
or individual arranging the adoption shall make arrangements for the insurance
to pay those costs that may be covered under that policy and shall advise the
adopting parent in writing of the existence and extent of the coverage without
disclosing any confidential information such as the identity of the natural
parent.� The insured adopting parents shall notify their insurer of the
existence and extent of the other coverage.
L. The director may disapprove any contract if the
benefits provided in the form of such contract are unreasonable in relation to
the premium charged.
M. The director shall adopt emergency rules
applicable to persons who are leaving active service in the armed forces of the
United States and returning to civilian status including:
1. Conditions of eligibility.
2. Coverage of dependents.
3. Preexisting conditions.
4. Termination of insurance.
5. Probationary periods.
6. Limitations.
7. Exceptions.
8. Reductions.
9. Elimination periods.
10. Requirements for replacement.
11. Any other condition of subscription contracts.
N. Any contract that provides maternity benefits
shall not restrict benefits for any hospital length of stay in connection with
childbirth for the mother or the newborn child to less than forty-eight
hours following a normal vaginal delivery or ninety-six hours following a
cesarean section.� The contract shall not require the provider to obtain
authorization from the corporation for prescribing the minimum length of stay
required by this subsection. The contract may provide that an
attending provider in consultation with the mother may discharge the mother or
the newborn child before the expiration of the minimum length of stay required
by this subsection.� The corporation shall not:
1. Deny the mother or the newborn child eligibility
or continued eligibility to enroll or to renew coverage under the terms of the
contract solely for the purpose of avoiding the requirements of this
subsection.
2. Provide monetary payments or rebates to mothers
to encourage those mothers to accept less than the minimum protections
available pursuant to this subsection.
3. Penalize or otherwise reduce or limit the
reimbursement of an attending provider because that provider provided care to
any insured under the contract in accordance with this subsection.
4. Provide monetary or other incentives to an
attending provider to induce that provider to provide care to an insured under
the contract in a manner that is inconsistent with this subsection.
5. Except as described in subsection O of this
section, restrict benefits for any portion of a period within the minimum
length of stay in a manner that is less favorable than the benefits provided
for any preceding portion of that stay.
O. Subsection N of this section does not:
1. Require a mother to give birth in a hospital or
to stay in the hospital for a fixed period of time following the birth of the
child.
2. Prevent a corporation from imposing deductibles,
coinsurance or other cost sharing in relation to benefits for hospital lengths
of stay in connection with childbirth for a mother or a newborn child under the
contract, except that any coinsurance or other cost sharing for any portion of
a period within a hospital length of stay required pursuant to subsection N of
this section shall not be greater than the coinsurance or cost sharing for any
preceding portion of that stay.
3. Prevent a corporation from negotiating the level
and type of reimbursement with a provider for care provided in accordance with
subsection N of this section.
P. Any contract that provides coverage for diabetes
shall also provide coverage for equipment and supplies that are medically
necessary and that are prescribed by a health care provider, including:
1. Blood glucose monitors.
2. Blood glucose monitors for the legally blind.
3. Test strips for glucose monitors and visual
reading and urine testing strips.
4. Insulin preparations and glucagon.
5. Insulin cartridges.
6. Drawing up devices and monitors for the visually
impaired.
7. Injection aids.
8. Insulin cartridges for the legally blind.
9. Syringes and lancets, including automatic lancing
devices.
10. Prescribed oral agents for controlling blood
sugar that are included on the plan formulary.
11. To the extent coverage is required under
medicare, podiatric appliances for prevention of complications associated with
diabetes.
12. Any other device, medication, equipment or
supply for which coverage is required under medicare from and after January 1,
1999. The coverage required in this paragraph is effective six
months after the coverage is required under medicare.
Q. Subsection P of this section does not prohibit a
medical service corporation, a hospital service corporation or a hospital,
medical, dental and optometric service corporation from imposing deductibles,
coinsurance or other cost sharing in relation to benefits for equipment or
supplies for the treatment of diabetes.
R. Any hospital or medical service contract that
provides coverage for prescription drugs shall not limit or exclude coverage
for any prescription drug prescribed for the treatment of cancer on the basis
that the prescription drug has not been approved by the United States food and
drug administration for the treatment of the specific type of cancer for which
the prescription drug has been prescribed, if the prescription drug has been
recognized as safe and effective for treatment of that specific type of cancer
in one or more of the standard medical reference compendia prescribed in
subsection S of this section or medical literature that meets the criteria
prescribed in subsection S of this section. The coverage required
under this subsection includes covered medically necessary services associated
with the administration of the prescription drug.� This subsection does not:
1. Require coverage of any prescription drug used in
the treatment of a type of cancer if the United States food and drug
administration has determined that the prescription drug is contraindicated for
that type of cancer.
2. Require coverage for any experimental
prescription drug that is not approved for any indication by the United States
food and drug administration.
3. Alter any law with regard to provisions that
limit the coverage of prescription drugs that have not been approved by the
United States food and drug administration.
4. Notwithstanding section 20-841.05, require
reimbursement or coverage for any prescription drug that is not included in the
drug formulary or list of covered prescription drugs specified in the contract.
5. Notwithstanding section 20-841.05, prohibit
a contract from limiting or excluding coverage of a prescription drug, if the
decision to limit or exclude coverage of the prescription drug is not based
primarily on the coverage of prescription drugs required by this section.
6. Prohibit the use of deductibles, coinsurance,
copayments or other cost sharing in relation to drug benefits and related
medical benefits offered.
S. For the purposes of subsection R of this section:
1. The acceptable standard medical reference
compendia are the following:
(a) The American hospital formulary service drug information,
a publication of the American society of health system pharmacists.
(b) The national comprehensive cancer network drugs
and biologics compendium.
(c) Thomson Micromedex compendium DrugDex.
(d) Elsevier gold standard's clinical pharmacology
compendium.
(e) Other authoritative compendia as identified by
the secretary of the United States department of health and human services.
2. Medical literature may be accepted if all of the
following apply:
(a) At least two articles from major peer reviewed
professional medical journals have recognized, based on scientific or medical
criteria, the drug's safety and effectiveness for treatment of the indication
for which the drug has been prescribed.
(b) No article from a major peer reviewed
professional medical journal has concluded, based on scientific or medical
criteria, that the drug is unsafe or ineffective or that the drug's safety and
effectiveness cannot be determined for the treatment of the indication for
which the drug has been prescribed.
(c) The literature meets the uniform requirements
for manuscripts submitted to biomedical journals established by the
international committee of medical journal editors or is published in a journal
specified by the United States department of health and human services as
acceptable peer reviewed medical literature pursuant to section 186(t)(2)(B) of
the social security act (42 United States Code section 1395x(t)(2)(B)).
T. A corporation shall not issue or deliver any
advertising matter or sales material to any person in this state until the
corporation files the advertising matter or sales material with the
director. This subsection does not require a corporation to have the
prior approval of the director to issue or deliver the advertising matter or
sales material.� If the director finds that the advertising matter or sales
material, in whole or in part, is false, deceptive or misleading, the director
may issue an order disapproving the advertising matter or sales material,
directing the corporation to cease and desist from issuing, circulating,
displaying or using the advertising matter or sales material within a period of
time specified by the director but not less than ten days and imposing any
penalties prescribed in this title. At least five days before
issuing an order pursuant to this subsection, the director shall provide the
corporation with a written notice of the basis of the order to provide the
corporation with an opportunity to cure the alleged deficiency in the
advertising matter or sales material within a single five-day period for
the particular advertising matter or sales material at issue.� The corporation
may appeal the director's order pursuant to title 41, chapter 6, article
10. Except as otherwise provided in this subsection, a corporation
may obtain a stay of the effectiveness of the order as prescribed in section 20-162.�
If the director certifies in the order and provides a detailed explanation of
the reasons in support of the certification that continued use of the
advertising matter or sales material poses a threat to the health, safety or
welfare of the public, the order may be entered immediately without opportunity
for cure and the effectiveness of the order is not stayed pending the hearing
on the notice of appeal but the hearing shall be promptly instituted and
determined.
U. Any contract that is offered by a hospital
service corporation or medical service corporation and that contains a
prescription drug benefit shall provide coverage of medical foods to treat
inherited metabolic disorders as provided by this section.
V. The metabolic disorders triggering medical foods
coverage under this section shall:
1. Be part of the newborn screening program
prescribed in section 36-694.
2. Involve amino acid, carbohydrate or fat
metabolism.
3. Have medically standard methods of diagnosis,
treatment and monitoring, including quantification of metabolites in blood,
urine or spinal fluid or enzyme or DNA confirmation in tissues.
4. Require specially processed or treated medical
foods that are generally available only under the supervision and direction of
a physician who is licensed pursuant to title 32, chapter 13 or 17 or a
registered nurse practitioner who is licensed pursuant to title 32, chapter 15,
that must be consumed throughout life and without which the person may suffer
serious mental or physical impairment.
W. Medical foods eligible for coverage under this
section shall be prescribed or ordered under the supervision of a physician
licensed pursuant to title 32, chapter 13 or 17 as medically necessary for the
therapeutic treatment of an inherited metabolic disease.
X. A hospital service corporation or medical service
corporation shall cover at least fifty percent of the cost of medical foods
prescribed to treat inherited metabolic disorders and covered pursuant to this
section.� A hospital service corporation or medical service corporation may
limit the maximum annual benefit for medical foods under this section to
$5,000, which applies to the cost of all prescribed modified low protein foods
and metabolic formula.
Y. Any contract between a corporation and its
subscribers is subject to the following:
1. If the contract provides coverage for
prescription drugs, the contract shall provide coverage for any prescribed drug
or device that is approved by the United States food and drug administration
for use as a contraceptive. A corporation may use a drug formulary,
multitiered drug formulary or list but that formulary or list shall include
oral, implant and injectable contraceptive drugs, intrauterine devices and
prescription barrier methods. The corporation may not impose
deductibles, coinsurance, copayments or other cost containment measures for
contraceptive drugs
,
that are greater than
the deductibles, coinsurance, copayments or other cost containment measures for
other drugs on the same level of the formulary or list
intrauterine devices, prescription barrier methods, over-the-counter
contraception, contraceptive implants, THERAPEUTIC equivalents or sterilization
.
2. If the contract provides coverage for outpatient
health care services, the contract shall provide coverage for outpatient
contraceptive services.� For the purposes of this paragraph, "outpatient
contraceptive services" means consultations, examinations, procedures and
medical services provided on an outpatient basis and related to the use of
approved United States food and drug administration prescription contraceptive
methods to prevent unintended pregnancies.
3. This subsection does not apply to contracts
issued to individuals on a nongroup basis.
Z. Notwithstanding subsection Y of
this section, a religiously affiliated employer may require that the
corporation provide a contract without coverage for specific items or services
required under subsection Y of this section because providing or paying for
coverage of the specific items or services is contrary to the religious beliefs
of the religiously affiliated employer offering the plan. If a
religiously affiliated employer objects to providing coverage for specific
items or services required under subsection Y of this section, a written
affidavit shall be filed with the corporation stating the
objection. On receipt of the affidavit, the corporation shall issue
to the religiously affiliated employer a contract that excludes coverage for specific
items or services required under subsection Y of this section.� The corporation
shall retain the affidavit for the duration of the contract and any renewals of
the contract. This subsection shall not exclude coverage for
prescription contraceptive methods ordered by a health care provider with
prescriptive authority for medical indications other than for contraceptive,
abortifacient, abortion or sterilization purposes. A religiously
affiliated employer offering the plan may state religious beliefs in its
affidavit and may require the subscriber to first pay for the prescription and
then submit a claim to the hospital service corporation, medical service
corporation or hospital, medical, dental and optometric service corporation
along with evidence that the prescription is not for a purpose covered by the
objection. A hospital service corporation, medical service
corporation or hospital, medical, dental and optometric service corporation may
charge an administrative fee for handling these claims.
AA. Subsection Z of this section does
not authorize a religiously affiliated employer to obtain an employee's
protected health information or to violate the health insurance portability and
accountability act of 1996 (P.L. 104-191; 110 Stat. 1936) or any federal
regulations adopted pursuant to that act.
BB. Subsection Z of this section does
not restrict or limit any protections against employment discrimination that
are prescribed in federal or state law.
CC.
Z.
For
the purposes of:
1. This section:
(a) "Inherited metabolic disorder" means a
disease caused by an inherited abnormality of body chemistry and includes a
disease tested under the newborn screening program prescribed in section 36-694.
(b) "Medical foods" means modified low
protein foods and metabolic formula.
(c) "Metabolic formula" means foods that
are all of the following:
(i) Formulated to be consumed or administered
enterally under the supervision of a physician who is licensed pursuant to
title 32, chapter 13 or 17.
(ii) Processed or formulated to be deficient in one
or more of the nutrients present in typical foodstuffs.
(iii) Administered for the medical and nutritional
management of a person who has limited capacity to metabolize foodstuffs or
certain nutrients contained in the foodstuffs or who has other specific
nutrient requirements as established by medical evaluation.
(iv) Essential to a person's optimal growth, health
and metabolic homeostasis.
(d) "Modified low protein foods" means
foods that are all of the following:
(i) Formulated to be consumed or administered
enterally under the supervision of a physician who is licensed pursuant to
title 32, chapter 13 or 17.
(ii) Processed or formulated to contain less than
one gram of protein per unit of serving, but does not include a natural food
that is naturally low in protein.
(iii) Administered for the medical and nutritional
management of a person who has limited capacity to metabolize foodstuffs or
certain nutrients contained in the foodstuffs or who has other specific
nutrient requirements as established by medical evaluation.
(iv) Essential to a person's optimal growth, health
and metabolic homeostasis.
2. Subsection E of this section, "child",
for purposes of initial coverage of an adopted child or a child placed for
adoption but not for purposes of termination of coverage of such child, means a
person who is under eighteen years of age.
3. Subsections Z and AA of this
section, "religiously affiliated employer" means either:
(a) An entity for which all of the
following apply:
(i) The entity primarily employs
persons who share the religious tenets of the entity.
(ii) The entity primarily serves
persons who share the religious tenets of the entity.
(iii) The entity is a nonprofit
organization as described in section 6033(a)(3)(A)(i) or (iii) of the internal
revenue code of 1986, as amended.
(b) An entity whose articles of
incorporation clearly state that it is a religiously motivated organization and
whose religious beliefs are central to the organization's operating principles.
END_STATUTE
Sec. 2. Section 20-1057.08, Arizona Revised
Statutes, is amended to read:
START_STATUTE
20-1057.08.
Prescription contraceptive drugs and devices
A. If a health care services organization issues
evidence of coverage that provides coverage for:
1. Prescription drugs, the evidence of coverage
shall provide coverage for any prescribed drug or device that is approved by
the United States food and drug administration for use as a contraceptive.� A
health care services organization may use a drug formulary, multitiered drug
formulary or list but that formulary or list shall include oral, implant and
injectable contraceptive drugs, intrauterine devices and prescription barrier
methods
.
if
The health care services
organization
does
may
not impose
deductibles, coinsurance, copayments or other cost containment measures for
contraceptive drugs
,
that are greater than
the deductibles, coinsurance, copayments or other cost containment measures for
other drugs on the same level of the formulary or list
intrauterine devices, prescription barrier methods, over-the-counter
contraception, contraceptive implants, THERAPEUTIC equivalents or sterilization
.
2. Outpatient health care services, the evidence of
coverage shall provide coverage for outpatient contraceptive services.� For the
purposes of this paragraph, "outpatient contraceptive services" means
consultations, examinations, procedures and medical services provided on an
outpatient basis and related to the use of
approved
United
States food and drug
administration
prescription
contraceptive methods to prevent unintended pregnancies.
B. Notwithstanding subsection A of
this section, a religiously affiliated employer may require that the health
care services organization provide an evidence of coverage without coverage for
specific items or services required under subsection A of this section because
providing or paying for coverage of the specific items or services is contrary
to the religious beliefs of the religiously affiliated employer offering the
plan.� If a religiously affiliated employer objects to providing coverage for
specific items or services required under subsection A of this section, a
written affidavit shall be filed with the health care services organization
stating the objection.� On receipt of the affidavit, the health care services
organization shall issue to the religiously affiliated employer an evidence of
coverage that excludes coverage for specific items or services required under
subsection A of this section. The health care services organization shall
retain the affidavit for the duration of the coverage and any renewals of the
coverage.
C. Subsection B of this section does
not exclude coverage for prescription contraceptive methods ordered by a health
care provider with prescriptive authority for medical indications other than
for contraceptive, abortifacient, abortion or sterilization
purposes. A religiously affiliated employer offering the plan may
state religious beliefs in its affidavit and may require the enrollee to first
pay for the prescription and then submit a claim to the health care services
organization along with evidence that the prescription is not for a purpose
covered by the objection. A health care services organization may
charge an administrative fee for handling claims under this subsection.
D. Subsections B and C of this section
do not authorize a religiously affiliated employer to obtain an employee's
protected health information or to violate the health insurance portability and
accountability act of 1996 (P.L. 104-191; 110 Stat. 1936) or any federal
regulations adopted pursuant to that act.
E. Subsections B and C of this section
shall not be construed to restrict or limit any protections against employment
discrimination that are prescribed in federal or state law.
F.
B.
This
section does not apply to evidences of coverage issued to individuals on a
nongroup basis.
G. For the purposes of this section,
"religiously affiliated employer" means either:
1. An entity for which all of the
following apply:
(a) The entity primarily employs
persons who share the religious tenets of the entity.
(b) The entity serves primarily
persons who share the religious tenets of the entity.
(c) The entity is a nonprofit
organization as described in section 6033(a)(3)(A)(i) or (iii) of the internal
revenue code of 1986, as amended.
2. An entity whose articles of
incorporation clearly state that it is a religiously motivated organization and
whose religious beliefs are central to the organization's operating principles.
END_STATUTE
Sec. 3. Title 20, chapter 6, article 4, Arizona
Revised Statutes, is amended by adding section 20-1376.11, to read:
START_STATUTE
20-1376.11.
Contraceptive coverage; prescriptions; male sterilization; cost
sharing prohibited
A disability insurance policy that includes
prescription drug coverage shall provide coverage for any prescribed drug or
device that is approved by the United States food and drug administration for
use as a contraceptive.� A disability insurance policy may not include any cost
sharing requirements for contraceptive drugs, intrauterine devices,
prescription barrier methods, over-the-counter contraception,
contraceptive implants, THERAPEUTIC equivalents or sterilization.
END_STATUTE
Sec. 4. Section 20-1402, Arizona Revised
Statutes, is amended to read:
START_STATUTE
20-1402.
Provisions of group disability policies; definitions
A. Each group disability
policy shall contain in substance the following provisions:
1. A provision that, in
the absence of fraud, all statements made by the policyholder or by any insured
person shall be deemed representations and not warranties, and that no
statement made for the purpose of effecting insurance shall avoid such
insurance or reduce benefits unless contained in a written instrument signed by
the policyholder or the insured person, a copy of which has been furnished to
the policyholder or to the person or beneficiary.
2. A provision that the
insurer will furnish to the policyholder, for delivery to each employee or
member of the insured group, an individual certificate setting forth in summary
form a statement of the essential features of the insurance coverage of the
employee or member and to whom benefits are payable. If dependents
or family members are included in the coverage additional certificates need not
be issued for delivery to the dependents or family members. Any
policy, except accidental death and dismemberment, applied for that provides
family coverage, as to such coverage of family members, shall also provide that
the benefits applicable for children shall be payable with respect to a newly
born child of the insured from the instant of such child's birth, to a child
adopted by the insured, regardless of the age at which the child was adopted,
and to a child who has been placed for adoption with the insured and for whom
the application and approval procedures for adoption pursuant to section 8-105
or 8-108 have been completed to the same extent that such coverage
applies to other members of the family.� The coverage for newly born or adopted
children or children placed for adoption shall include coverage of injury or
sickness including the necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities.� If payment of a specific premium
is required to provide coverage for a child, the policy may require that
notification of birth, adoption or adoption placement of the child and payment
of the required premium must be furnished to the insurer within thirty-one
days after the date of birth, adoption or adoption placement in order to have
the coverage continue beyond such thirty-one day period.
3. A provision that to the
group originally insured may be added from time to time eligible new employees
or members or dependents, as the case may be, in accordance with the terms of
the policy.
4. Each contract shall be
so written that the corporation shall pay benefits:
(a) For performance of any
surgical service that is covered by the terms of such contract, regardless of
the place of service.
(b) For any home health
services that are performed by a licensed home health agency and that a
physician has prescribed in lieu of hospital services, as defined by the
director, providing the hospital services would have been covered.
(c) For any diagnostic
service that a physician has performed outside a hospital in lieu of inpatient
service, providing the inpatient service would have been covered.
(d) For any service
performed in a hospital's outpatient department or in a freestanding surgical
facility, providing such service would have been covered if performed as an
inpatient service.
5. A group disability
insurance policy that provides coverage for the surgical expense of a
mastectomy shall also provide coverage incidental to the patient's covered
mastectomy for the expense of reconstructive surgery of the breast on which the
mastectomy was performed, surgery and reconstruction of the other breast to
produce a symmetrical appearance, prostheses, treatment of physical
complications for all stages of the mastectomy, including lymphedemas, and at
least two external postoperative prostheses subject to all of the terms and
conditions of the policy.
6. A contract, except a
supplemental contract covering a specified disease or other limited benefits,
that provides coverage for surgical services for a mastectomy shall also
provide coverage for preventive mammography screening and diagnostic imaging
performed on dedicated equipment for diagnostic purposes on referral by a
patient's physician, subject to all of the terms and conditions of the policy,
including:
(a) A mammogram.
(b) Digital breast
tomosynthesis, magnetic resonance imaging, ultrasound or other modality and at
such age and intervals as recommended by the national comprehensive cancer
network.� This includes patients at risk for breast cancer who have a family
history with one or more first or second degree relatives with breast cancer,
prior diagnosis of breast cancer, positive testing for hereditary gene
mutations or heterogeneously or dense breast tissue based on the breast imaging
reporting and data system of the American college of radiology.
7. Any contract that is
issued to the insured and that provides coverage for maternity benefits shall
also provide that the maternity benefits apply to the costs of the birth of any
child legally adopted by the insured if all the following are true:
(a) The child is adopted within one year of birth.
(b) The insured is legally obligated to pay the
costs of birth.
(c) All preexisting
conditions and other limitations have been met by the insured.
(d) The insured has
notified the insurer of the insured's acceptability to adopt children pursuant
to section 8-105, within sixty days after such approval or within sixty
days after a change in insurance policies, plans or companies.
8. The coverage prescribed
by paragraph 7 of this subsection is excess to any other coverage the natural
mother may have for maternity benefits except coverage made available to
persons pursuant to title 36, chapter 29. If such other coverage
exists the agency, attorney or individual arranging the adoption shall make
arrangements for the insurance to pay those costs that may be covered under
that policy and shall advise the adopting parent in writing of the existence
and extent of the coverage without disclosing any confidential information such
as the identity of the natural parent. The insured adopting parents
shall notify their insurer of the existence and extent of the other coverage.
B. Any policy that
provides maternity benefits shall not restrict benefits for any hospital length
of stay in connection with childbirth for the mother or the newborn child to
less than forty-eight hours following a normal vaginal delivery or ninety-six
hours following a cesarean section.� The policy shall not require the provider
to obtain authorization from the insurer for prescribing the minimum length of
stay required by this subsection. The policy may provide that an
attending provider in consultation with the mother may discharge the mother or
the newborn child before the expiration of the minimum length of stay required
by this subsection.� The insurer shall not:
1. Deny the mother or the
newborn child eligibility or continued eligibility to enroll or to renew
coverage under the terms of the policy solely for the purpose of avoiding the
requirements of this subsection.
2. Provide monetary
payments or rebates to mothers to encourage those mothers to accept less than
the minimum protections available pursuant to this subsection.
3. Penalize or otherwise
reduce or limit the reimbursement of an attending provider because that
provider provided care to any insured under the policy in accordance with this
subsection.
4. Provide monetary or
other incentives to an attending provider to induce that provider to provide
care to an insured under the policy in a manner that is inconsistent with this
subsection.
5. Except as described in
subsection C of this section, restrict benefits for any portion of a period
within the minimum length of stay in a manner that is less favorable than the
benefits provided for any preceding portion of that stay.
C. Subsection B of this
section does not:
1. Require a mother to
give birth in a hospital or to stay in the hospital for a fixed period of time
following the birth of the child.
2. Prevent an insurer from
imposing deductibles, coinsurance or other cost sharing in relation to benefits
for hospital lengths of stay in connection with childbirth for a mother or a
newborn child under the policy, except that any coinsurance or other cost
sharing for any portion of a period within a hospital length of stay required
pursuant to subsection B of this section shall not be greater than the
coinsurance or cost sharing for any preceding portion of that stay.
3. Prevent an insurer from
negotiating the level and type of reimbursement with a provider for care
provided in accordance with subsection B of this section.
D. Any contract that
provides coverage for diabetes shall also provide coverage for equipment and
supplies that are medically necessary and that are prescribed by a health care
provider including:
1. Blood glucose monitors.
2. Blood glucose monitors
for the legally blind.
3. Test strips for glucose
monitors and visual reading and urine testing strips.
4. Insulin preparations
and glucagon.
5. Insulin cartridges.
6. Drawing up devices and
monitors for the visually impaired.
7. Injection aids.
8. Insulin cartridges for
the legally blind.
9. Syringes and lancets
including automatic lancing devices.
10. Prescribed oral agents for controlling blood
sugar that are included on the plan formulary.
11. To the extent coverage is required under
medicare, podiatric appliances for prevention of complications associated with
diabetes.
12. Any other device, medication, equipment or
supply for which coverage is required under medicare from and after January 1,
1999. The coverage required in this paragraph is effective six
months after the coverage is required under medicare.
E. Subsection D of this
section does not prohibit a group disability insurer from imposing deductibles,
coinsurance or other cost sharing in relation to benefits for equipment or
supplies for the treatment of diabetes.
F. Any contract that
provides coverage for prescription drugs shall not limit or exclude coverage
for any prescription drug prescribed for the treatment of cancer on the basis
that the prescription drug has not been approved by the United States food and
drug administration for the treatment of the specific type of cancer for which
the prescription drug has been prescribed, if the prescription drug has been
recognized as safe and effective for treatment of that specific type of cancer
in one or more of the standard medical reference compendia prescribed in
subsection G of this section or medical literature that meets the criteria
prescribed in subsection G of this section.� The coverage required under this
subsection includes covered medically necessary services associated with the
administration of the prescription drug.� This subsection does not:
1. Require coverage of any
prescription drug used in the treatment of a type of cancer if the United
States food and drug administration has determined that the prescription drug
is contraindicated for that type of cancer.
2. Require coverage for
any experimental prescription drug that is not approved for any indication by
the United States food and drug administration.
3. Alter any law with
regard to provisions that limit the coverage of prescription drugs that have
not been approved by the United States food and drug administration.
4. Require reimbursement
or coverage for any prescription drug that is not included in the drug
formulary or list of covered prescription drugs specified in the contract.
5. Prohibit a contract
from limiting or excluding coverage of a prescription drug, if the decision to
limit or exclude coverage of the prescription drug is not based primarily on
the coverage of prescription drugs required by this section.
6. Prohibit the use of
deductibles, coinsurance, copayments or other cost sharing in relation to drug
benefits and related medical benefits offered.
G. For the purposes of
subsection F of this section:
1. The acceptable standard
medical reference compendia are the following:
(a) The American hospital
formulary service drug information, a publication of the American society of
health system pharmacists.
(b) The national comprehensive cancer network drugs
and biologics compendium.
(c) Thomson Micromedex compendium DrugDex.
(d) Elsevier gold standard's clinical pharmacology
compendium.
(e) Other authoritative
compendia as identified by the secretary of the United States department of
health and human services.
2. Medical literature may
be accepted if all of the following apply:
(a) At least two articles
from major peer reviewed professional medical journals have recognized, based
on scientific or medical criteria, the drug's safety and effectiveness for
treatment of the indication for which the drug has been prescribed.
(b) No article from a
major peer reviewed professional medical journal has concluded, based on
scientific or medical criteria, that the drug is unsafe or ineffective or that
the drug's safety and effectiveness cannot be determined for the treatment of
the indication for which the drug has been prescribed.
(c) The literature meets
the uniform requirements for manuscripts submitted to biomedical journals
established by the international committee of medical journal editors or is
published in a journal specified by the United States department of health and
human services as acceptable peer reviewed medical literature pursuant to
section 186(t)(2)(B) of the social security act (42 United States Code section
1395x(t)(2)(B)).
H. Any contract that is
offered by a group disability insurer and that contains a prescription drug
benefit shall provide coverage of medical foods to treat inherited metabolic
disorders as provided by this section.
I. The metabolic disorders
triggering medical foods coverage under this section shall:
1. Be part of the newborn
screening program prescribed in section 36-694.
2. Involve amino acid,
carbohydrate or fat metabolism.
3. Have medically standard
methods of diagnosis, treatment and monitoring including quantification of
metabolites in blood, urine or spinal fluid or enzyme or DNA confirmation in
tissues.
4. Require specially
processed or treated medical foods that are generally available only under the
supervision and direction of a physician who is licensed pursuant to title 32,
chapter 13 or 17
or a registered nurse practitioner
who is licensed pursuant to title 32, chapter 15, that must be consumed
throughout life and without which the person may suffer serious mental or
physical impairment.
J. Medical foods eligible
for coverage under this section shall be prescribed or ordered under the
supervision of a physician licensed pursuant to title 32, chapter 13 or 17 or a
registered nurse practitioner who is licensed pursuant to title 32, chapter 15
as medically necessary for the therapeutic treatment of an inherited metabolic
disease.
K. An insurer shall cover
at least fifty percent of the cost of medical foods prescribed to treat
inherited metabolic disorders and covered pursuant to this section.� An insurer
may limit the maximum annual benefit for medical foods under this section to
$5,000, which applies to the cost of all prescribed modified low protein foods
and metabolic formula.
L. Any group disability
policy that provides coverage for:
1. Prescription drugs shall also provide coverage
for any prescribed drug or device that is approved by the United States food
and drug administration for use as a contraceptive. A group
disability insurer may use a drug formulary, multitiered drug formulary or list
but that formulary or list shall include oral, implant and injectable
contraceptive drugs, intrauterine devices and prescription barrier
methods. The group disability insurer may not impose deductibles,
coinsurance, copayments or other cost containment measures for contraceptive
drugs
,
that are greater than the
deductibles, coinsurance, copayments or other cost containment measures for
other drugs on the same level of the formulary or list
intrauterine devices, prescription barrier methods, over-the-counter
contraception, contraceptive implants, THERAPEUTIC equivalents or sterilization
.
2. Outpatient health care services shall also
provide coverage for outpatient contraceptive services.� For the purposes of
this paragraph, "outpatient contraceptive services" means
consultations, examinations, procedures and medical services provided on an
outpatient basis and related to the use of approved United States food and drug
administration prescription contraceptive methods to prevent unintended
pregnancies.
M. Notwithstanding subsection L of
this section, a religiously affiliated employer may require that the insurer
provide a group disability policy without coverage for specific items or
services required under subsection L of this section because providing or
paying for coverage of the specific items or services is contrary to the
religious beliefs of the religiously affiliated employer offering the
plan. If a religiously affiliated employer objects to providing
coverage for specific items or services required under subsection L of this
section, a written affidavit shall be filed with the insurer stating the
objection. On receipt of the affidavit, the insurer shall issue to
the religiously affiliated employer a group disability policy that excludes
coverage for specific items or services required under subsection L of this
section.� The insurer shall retain the affidavit for the duration of the group
disability policy and any renewals of the policy. This subsection
shall not exclude coverage for prescription contraceptive methods ordered by a
health care provider with prescriptive authority for medical indications other
than for contraceptive, abortifacient, abortion or sterilization
purposes. A religiously affiliated employer offering the policy may
state religious beliefs in its affidavit and may require the insured to first
pay for the prescription and then submit a claim to the insurer along with
evidence that the prescription is not for a purpose covered by the
objection. An insurer may charge an administrative fee for handling
these claims.
N. Subsection M of this section does
not authorize a religiously affiliated employer to obtain an employee's
protected health information or to violate the health insurance portability and
accountability act of 1996 (P.L. 104-191; 110 Stat. 1936) or any federal
regulations adopted pursuant to that act.
O. Subsection M of this section shall
not be construed to restrict or limit any protections against employment
discrimination that are prescribed in federal or state law.
P.
M.
For the purposes of:
1. This section:
(a) "Inherited
metabolic disorder" means a disease caused by an inherited abnormality of
body chemistry and includes a disease tested under the newborn screening
program prescribed in section 36-694.
(b) "Medical
foods" means modified low protein foods and metabolic formula.
(c) "Metabolic
formula" means foods that are all of the following:
(i) Formulated to be
consumed or administered enterally under the supervision of a physician who is
licensed pursuant to title 32, chapter 13 or 17
or a
registered nurse practitioner who is licensed pursuant to title 32, chapter 15.
(ii) Processed or
formulated to be deficient in one or more of the nutrients present in typical
foodstuffs.
(iii) Administered for the
medical and nutritional management of a person who has limited capacity to
metabolize foodstuffs or certain nutrients contained in the foodstuffs or who
has other specific nutrient requirements as established by medical evaluation.
(iv) Essential to a
person's optimal growth, health and metabolic homeostasis.
(d) "Modified low
protein foods" means foods that are all of the following:
(i) Formulated to be
consumed or administered enterally under the supervision of a physician who is
licensed pursuant to title 32, chapter 13 or 17
or a
registered nurse practitioner who is licensed pursuant to title 32, chapter 15.
(ii) Processed or
formulated to contain less than one gram of protein per unit of serving, but
does not include a natural food that is naturally low in protein.
(iii) Administered for the
medical and nutritional management of a person who has limited capacity to
metabolize foodstuffs or certain nutrients contained in the foodstuffs or who
has other specific nutrient requirements as established by medical evaluation.
(iv) Essential to a
person's optimal growth, health and metabolic homeostasis.
2. Subsection A of this
section,
the term
"child", for purposes of
initial coverage of an adopted child or a child placed for adoption but not for
purposes of termination of coverage of such child, means a person who is under
eighteen years of age.
3. Subsections M and N of this
section, "religiously affiliated employer" means either:
(a) An entity for which all of the
following apply:
(i) The entity primarily employs
persons who share the religious tenets of the entity.
(ii) The entity serves primarily persons
who share the religious tenets of the entity.
(iii) The entity is a nonprofit
organization as described in section 6033(a)(3)(A)(i) or (iii) of the internal
revenue code of 1986, as amended.
(b) An entity whose articles of
incorporation clearly state that it is a religiously motivated organization and
whose religious beliefs are central to the organization's operating principles.
END_STATUTE
Sec. 5. Section 20-1404, Arizona Revised
Statutes, is amended to read:
START_STATUTE
20-1404.
Blanket disability insurance; definitions
A. Blanket disability insurance is that form of
disability insurance covering special groups of persons as enumerated in one of
the following paragraphs:
1. Under a policy or contract issued to any common
carrier or to any operator, owner or lessee of a means of transportation, which
shall be deemed the policyholder, covering a group defined as all persons who
may become passengers on such common carrier or means of transportation.
2. Under a policy or contract issued to an employer,
who shall be deemed the policyholder, covering all employees or any group of
employees defined by reference to hazards incident to an activity or activities
or operations of the policyholder.� Dependents of the employees and guests of
the employer or employees may also be included where exposed to the same
hazards.
3. Under a policy or contract issued to a college,
school or other institution of learning or to the head or principal thereof,
who or which shall be deemed the policyholder, covering students, teachers,
employees or volunteers.
4. Under a policy or contract issued in the name of
any volunteer fire department or any first aid, civil defense or other such
volunteer group, or agency having jurisdiction thereof, which shall be deemed
the policyholder, covering all or any group of the members, participants or
volunteers of the fire department or first aid, civil defense or other group.
5. Under a policy or contract issued to a creditor,
who shall be deemed the policyholder, to insure debtors of the creditor.
6. Under a policy or contract issued to a sports
team or to a camp or sponsor thereof, which team or camp or sponsor thereof
shall be deemed the policyholder, covering members, campers, employees,
officials, supervisors or volunteers.
7. Under a policy or contract issued to an
incorporated or unincorporated religious, charitable, recreational, educational
or civic organization, or branch thereof, which organization shall be deemed
the policyholder, covering any group of members, participants or volunteers
defined by reference to hazards incident to an activity or activities or
operations sponsored or supervised by or on the premises of the policyholder.
8. Under a policy or contract issued to a newspaper
or other publisher, which shall be deemed the policyholder, covering its
carriers.
9. Under a policy or contract issued to a
restaurant, hotel, motel, resort, innkeeper or other group with a high degree
of potential customer liability, which shall be deemed the policyholder,
covering patrons or guests.
10. Under a policy or contract issued to a health
care provider or other arranger of health services, which shall be deemed the
policyholder, covering patients, donors or surrogates provided that the
coverage is not made a condition of receiving care.
11. Under a policy or contract issued to a bank,
financial vendor or other financial institution, or to a parent holding company
or to the trustee, trustees or agent designated by one or more banks, financial
vendors or other financial institutions, which shall be deemed the
policyholder, covering account holders, debtors, guarantors or purchasers.
12. Under a policy or contract issued to an
incorporated or unincorporated association of persons having a common interest
or calling, which association shall be deemed the policyholder, formed for
purposes other than obtaining insurance, covering members of such association.
13. Under a policy or contract issued to a travel
agency or other organization that provides travel-related services, which
agency or organization shall be deemed the policyholder, to cover all persons
for whom travel-related services are provided.
14. Under a policy or contract issued to a qualified
marketplace platform, which is deemed the policyholder, covering qualified
marketplace contractors that have executed a written contract with the
qualified marketplace platform.� For the purposes of this paragraph,
"qualified marketplace contractor" and "qualified marketplace
platform" have the same meanings prescribed in section 20-485.
15. Under a policy or contract that is issued to any
other substantially similar group and that, in the discretion of the director,
may be subject to the issuance of a blanket disability policy or contract.� The
director may exercise discretion on an individual risk basis or class of risks,
or both.
B. An individual application need not be required
from a person covered under a blanket disability policy or contract, nor shall
it be necessary for the insurer to furnish each person with a certificate.
C. All benefits under any blanket disability policy
shall be payable to the person insured, or to the insured's designated
beneficiary or beneficiaries, or to the insured's estate, except that if the
person insured is a minor, such benefits may be made payable to the insured's
parent or guardian or any other person actually supporting the insured, and
except that the policy may provide that all or any portion of any indemnities
provided by any such policy on account of hospital, nursing, medical or surgical
services, at the insurer's option, may be paid directly to the hospital or
person rendering such services, but the policy may not require that the service
be rendered by a particular hospital or person.� Payment so made shall
discharge the insurer's obligation with respect to the amount of insurance so
paid.
D. This section does not affect the legal liability
of policyholders for the death of or injury to any member of the group.
E. Any policy or contract, except accidental death
and dismemberment, applied for that provides family coverage, as to such
coverage of family members, shall also provide that the benefits applicable for
children shall be payable with respect to a newly born child of the insured
from the instant of such child's birth, to a child adopted by the insured,
regardless of the age at which the child was adopted, and to a child who has
been placed for adoption with the insured and for whom the application and approval
procedures for adoption pursuant to section 8-105 or 8-108 have
been completed to the same extent that such coverage applies to other members
of the family. The coverage for newly born or adopted children or
children placed for adoption shall include coverage of injury or sickness
including necessary care and treatment of medically diagnosed congenital
defects and birth abnormalities. If payment of a specific premium is
required to provide coverage for a child, the policy or contract may require
that notification of birth, adoption or adoption placement of the child and
payment of the required premium must be furnished to the insurer within thirty-one
days after the date of birth, adoption or adoption placement in order to have
the coverage continue beyond the thirty-one day period.
F. Each policy or contract shall be so written that
the insurer shall pay benefits:
1. For performance of any surgical service that is
covered by the terms of such contract, regardless of the place of service.
2. For any home health services that are performed
by a licensed home health agency and that a physician has prescribed in lieu of
hospital services, as defined by the director, providing the hospital services
would have been covered.
3. For any diagnostic service that a physician has
performed outside a hospital in lieu of inpatient service, providing the
inpatient service would have been covered.
4. For any service performed in a hospital's
outpatient department or in a freestanding surgical facility, providing such
service would have been covered if performed as an inpatient service.
G. A blanket disability insurance policy that
provides coverage for the surgical expense of a mastectomy shall also provide
coverage incidental to the patient's covered mastectomy for the expense of
reconstructive surgery of the breast on which the mastectomy was performed,
surgery and reconstruction of the other breast to produce a symmetrical
appearance, prostheses, treatment of physical complications for all stages of
the mastectomy, including lymphedemas, and at least two external postoperative
prostheses subject to all of the terms and conditions of the policy.
H. A contract that provides coverage for surgical
services for a mastectomy shall also provide coverage for preventive
mammography screening and diagnostic imaging performed on dedicated equipment
for diagnostic purposes on referral by a patient's physician, subject to all of
the terms and conditions of the policy, including:
1. A mammogram.
2. Digital breast
tomosynthesis, magnetic resonance imaging, ultrasound or other modality and at
such age and intervals as recommended by the national comprehensive cancer
network.� This includes patients at risk for breast cancer who have a family
history with one or more first or second degree relatives with breast cancer,
prior diagnosis of breast cancer, positive testing for hereditary gene
mutations or heterogeneously or dense breast tissue based on the breast imaging
reporting and data system of the American college of radiology.
I. Any contract that is issued to the insured and
that provides coverage for maternity benefits shall also provide that the
maternity benefits apply to the costs of the birth of any child legally adopted
by the insured if all the following are true:
1. The child is adopted within one year of birth.
2. The insured is legally obligated to pay the costs
of birth.
3. All preexisting conditions and other limitations
have been met by the insured.
4. The insured has notified the insurer of his
acceptability to adopt children pursuant to section 8-105, within sixty
days after such approval or within sixty days after a change in insurance
policies, plans or companies.
J. The coverage prescribed by subsection I of this
section is excess to any other coverage the natural mother may have for
maternity benefits except coverage made available to persons pursuant to title
36, chapter 29. If such other coverage exists the agency, attorney
or individual arranging the adoption shall make arrangements for the insurance
to pay those costs that may be covered under that policy and shall advise the
adopting parent in writing of the existence and extent of the coverage without
disclosing any confidential information such as the identity of the natural
parent.� The insured adopting parents shall notify their insurer of the
existence and extent of the other coverage.
K. Any contract that provides maternity benefits
shall not restrict benefits for any hospital length of stay in connection with
childbirth for the mother or the newborn child to less than forty-eight
hours following a normal vaginal delivery or ninety-six hours following a
cesarean section.� The contract shall not require the provider to obtain
authorization from the insurer for prescribing the minimum length of stay
required by this subsection. The contract may provide that an
attending provider in consultation with the mother may discharge the mother or
the newborn child before the expiration of the minimum length of stay required
by this subsection.� The insurer shall not:
1. Deny the mother or the newborn child eligibility
or continued eligibility to enroll or to renew coverage under the terms of the
contract solely for the purpose of avoiding the requirements of this
subsection.
2. Provide monetary payments or rebates to mothers
to encourage those mothers to accept less than the minimum protections
available pursuant to this subsection.
3. Penalize or otherwise reduce or limit the
reimbursement of an attending provider because that provider provided care to
any insured under the contract in accordance with this subsection.
4. Provide monetary or other incentives to an
attending provider to induce that provider to provide care to an insured under
the contract in a manner that is inconsistent with this subsection.
5. Except as described in subsection L of this
section, restrict benefits for any portion of a period within the minimum
length of stay in a manner that is less favorable than the benefits provided
for any preceding portion of that stay.
L. Subsection K of this section does not:
1. Require a mother to give birth in a hospital or
to stay in the hospital for a fixed period of time following the birth of the
child.
2. Prevent an insurer from imposing deductibles,
coinsurance or other cost sharing in relation to benefits for hospital lengths
of stay in connection with childbirth for a mother or a newborn child under the
contract, except that any coinsurance or other cost sharing for any portion of
a period within a hospital length of stay required pursuant to subsection K of
this section shall not be greater than the coinsurance or cost sharing for any
preceding portion of that stay.
3. Prevent an insurer from negotiating the level and
type of reimbursement with a provider for care provided in accordance with
subsection K of this section.
M. Any contract that provides coverage for diabetes
shall also provide coverage for equipment and supplies that are medically
necessary and that are prescribed by a health care provider including:
1. Blood glucose monitors.
2. Blood glucose monitors for the legally blind.
3. Test strips for glucose monitors and visual
reading and urine testing strips.
4. Insulin preparations and glucagon.
5. Insulin cartridges.
6. Drawing up devices and monitors for the visually
impaired.
7. Injection aids.
8. Insulin cartridges for the legally blind.
9. Syringes and lancets including automatic lancing
devices.
10. Prescribed oral agents for controlling blood
sugar that are included on the plan formulary.
11. To the extent coverage is required under
medicare, podiatric appliances for prevention of complications associated with
diabetes.
12. Any other device, medication, equipment or
supply for which coverage is required under medicare from and after January 1,
1999. The coverage required in this paragraph is effective six
months after the coverage is required under medicare.
N. Subsection M of this section does not prohibit a
blanket disability insurer from imposing deductibles, coinsurance or other cost
sharing in relation to benefits for equipment or supplies for the treatment of
diabetes.
O. Any contract that provides coverage for
prescription drugs shall not limit or exclude coverage for any prescription
drug prescribed for the treatment of cancer on the basis that the prescription
drug has not been approved by the United States food and drug administration
for the treatment of the specific type of cancer for which the prescription
drug has been prescribed, if the prescription drug has been recognized as safe
and effective for treatment of that specific type of cancer in one or more of
the standard medical reference compendia prescribed in subsection P of this
section or medical literature that meets the criteria prescribed in subsection
P of this section.� The coverage required under this subsection includes
covered medically necessary services associated with the administration of the
prescription drug.� This subsection does not:
1. Require coverage of any prescription drug used in
the treatment of a type of cancer if the United States food and drug
administration has determined that the prescription drug is contraindicated for
that type of cancer.
2. Require coverage for any experimental
prescription drug that is not approved for any indication by the United States
food and drug administration.
3. Alter any law with regard to provisions that
limit the coverage of prescription drugs that have not been approved by the
United States food and drug administration.
4. Require reimbursement or coverage for any
prescription drug that is not included in the drug formulary or list of covered
prescription drugs specified in the contract.
5. Prohibit a contract from limiting or excluding
coverage of a prescription drug, if the decision to limit or exclude coverage
of the prescription drug is not based primarily on the coverage of prescription
drugs required by this section.
6. Prohibit the use of deductibles, coinsurance,
copayments or other cost sharing in relation to drug benefits and related
medical benefits offered.
P. For the purposes of subsection O of this section:
1. The acceptable standard medical reference
compendia are the following:
(a) The American hospital formulary service drug
information, a publication of the American society of health system
pharmacists.
(b) The national comprehensive cancer network drugs
and biologics compendium.
(c) Thomson Micromedex compendium DrugDex.
(d) Elsevier gold standard's clinical pharmacology
compendium.
(e) Other authoritative compendia as identified by
the secretary of the United States department of health and human services.
2. Medical literature may be accepted if all of the
following apply:
(a) At least two articles from major peer reviewed
professional medical journals have recognized, based on scientific or medical
criteria, the drug's safety and effectiveness for treatment of the indication
for which the drug has been prescribed.
(b) No article from a major peer reviewed
professional medical journal has concluded, based on scientific or medical
criteria, that the drug is unsafe or ineffective or that the drug's safety and
effectiveness cannot be determined for the treatment of the indication for
which the drug has been prescribed.
(c) The literature meets the uniform requirements
for manuscripts submitted to biomedical journals established by the
international committee of medical journal editors or is published in a journal
specified by the United States department of health and human services as
acceptable peer reviewed medical literature pursuant to section 186(t)(2)(B) of
the social security act (42 United States Code section 1395x(t)(2)(B)).
Q. Any contract that is offered by a blanket
disability insurer and that contains a prescription drug benefit shall provide
coverage of medical foods to treat inherited metabolic disorders as provided by
this section.
R. The metabolic
disorders triggering medical foods coverage under this section shall:
1. Be part of the
newborn screening program prescribed in section 36-694.
2. Involve amino acid, carbohydrate or fat
metabolism.
3. Have medically standard methods of diagnosis,
treatment and monitoring including quantification of metabolites in blood,
urine or spinal fluid or enzyme or DNA confirmation in tissues.
4. Require specially processed or treated medical
foods that are generally available only under the supervision and direction of
a physician who is licensed pursuant to title 32, chapter 13 or 17
or a registered nurse practitioner who is licensed
pursuant to title 32, chapter 15, that must be consumed throughout life and
without which the person may suffer serious mental or physical impairment.
S. Medical foods eligible for coverage under this
section shall be prescribed or ordered under the supervision of a physician
licensed pursuant to title 32, chapter 13 or 17 or a registered nurse
practitioner who is licensed pursuant to title 32, chapter 15 as medically
necessary for the therapeutic treatment of an inherited metabolic disease.
T. An insurer shall cover at least fifty percent of
the cost of medical foods prescribed to treat inherited metabolic disorders and
covered pursuant to this section.� An insurer may limit the maximum annual
benefit for medical foods under this section to $5,000, which applies to the
cost of all prescribed modified low protein foods and metabolic formula.
U. Any blanket disability policy that provides
coverage for:
1. Prescription drugs shall also provide coverage
for any prescribed drug or device that is approved by the United States food
and drug administration for use as a contraceptive. A blanket
disability insurer may use a drug formulary, multitiered drug formulary or list
but that formulary or list shall include oral, implant and injectable
contraceptive drugs, intrauterine devices and prescription barrier
methods. The blanket disability insurer may not impose deductibles,
coinsurance, copayments or other cost containment measures for contraceptive
drugs
,
that are greater than the
deductibles, coinsurance, copayments or other cost containment measures for
other drugs on the same level of the formulary or list
INTRAUTERINE DEVICES, PRESCRIPTION BARRIER METHODS, over-the-counter
contraception, contraceptive implants, THERAPEUTIC equivalents OR STERILIZATION
.
2. Outpatient health care services shall also
provide coverage for outpatient contraceptive services. For the
purposes of this paragraph, "outpatient contraceptive services" means
consultations, examinations, procedures and medical services provided on an
outpatient basis and related to the use of approved United States food and drug
administration prescription contraceptive methods to prevent unintended
pregnancies.
V. Notwithstanding subsection U of
this section, a religiously affiliated employer may require that the insurer
provide a blanket disability policy without coverage for specific items or
services required under subsection U of this section because providing or
paying for coverage of the specific items or services is contrary to the
religious beliefs of the religiously affiliated employer offering the
plan. If a religiously affiliated employer objects to providing
coverage for specific items or services required under subsection U of this
section, a written affidavit shall be filed with the insurer stating the
objection. On receipt of the affidavit, the insurer shall issue to
the religiously affiliated employer a blanket disability policy that excludes
coverage for specific items or services required under subsection U of this
section. The insurer shall retain the affidavit for the duration of the blanket
disability policy and any renewals of the policy. This subsection
shall not exclude coverage for prescription contraceptive methods ordered by a
health care provider with prescriptive authority for medical indications other
than for contraceptive, abortifacient, abortion or sterilization purposes.� A
religiously affiliated employer offering the policy may state religious beliefs
in its affidavit and may require the insured to first pay for the prescription
and then submit a claim to the insurer along with evidence that the
prescription is not for a purpose covered by the objection.� An insurer may
charge an administrative fee for handling these claims under this subsection.
W. Subsection V of this section does
not authorize a religiously affiliated employer to obtain an employee's
protected health information or to violate the health insurance portability and
accountability act of 1996 (P.L. 104-191; 110 Stat. 1936) or any federal
regulations adopted pursuant to that act.
X. Subsection V of this section shall
not be construed to restrict or limit any protections against employment
discrimination that are prescribed in federal or state law.
Y.
V.
For
the purposes of:
1. This section:
(a) "Inherited metabolic disorder" means a
disease caused by an inherited abnormality of body chemistry and includes a
disease tested under the newborn screening program prescribed in section 36-694.
(b) "Medical foods" means modified low
protein foods and metabolic formula.
(c) "Metabolic formula" means foods that
are all of the following:
(i) Formulated to be consumed or administered
enterally under the supervision of a physician who is licensed pursuant to
title 32, chapter 13 or 17
or a registered nurse
practitioner who is licensed pursuant to title 32, chapter 15.
(ii) Processed or formulated to be deficient in one
or more of the nutrients present in typical foodstuffs.
(iii) Administered for the medical and nutritional
management of a person who has limited capacity to metabolize foodstuffs or
certain nutrients contained in the foodstuffs or who has other specific
nutrient requirements as established by medical evaluation.
(iv) Essential to a person's optimal growth, health
and metabolic homeostasis.
(d) "Modified low protein foods" means
foods that are all of the following:
(i) Formulated to be consumed or administered
enterally under the supervision of a physician who is licensed pursuant to
title 32, chapter 13 or 17 or a registered nurse practitioner who is licensed
pursuant to title 32, chapter 15.
(ii) Processed or formulated to contain less than
one gram of protein per unit of serving, but does not include a natural food
that is naturally low in protein.
(iii) Administered for the medical and nutritional
management of a person who has limited capacity to metabolize foodstuffs or
certain nutrients contained in the foodstuffs or who has other specific
nutrient requirements as established by medical evaluation.
(iv) Essential to a person's optimal growth, health
and metabolic homeostasis.
2. Subsection E of this section,
the
term
"child", for purposes of initial coverage of an adopted
child or a child placed for adoption but not for purposes of termination of
coverage of such child, means a person who is under eighteen years of age.
3. Subsections V and W of this
section, "religiously affiliated employer" means either:
(a) An entity for which all of the
following apply:
(i) The entity primarily employs
persons who share the religious tenets of the entity.
(ii) The entity serves primarily
persons who share the religious tenets of the entity.
(iii) The entity is a nonprofit
organization as described in section 6033(a)(3)(A)(i) or (iii) of the internal
revenue code of 1986, as amended.
(b) An entity whose articles of
incorporation clearly state that it is a religiously motivated organization and
whose religious beliefs are central to the organization's operating principles.
END_STATUTE