Maine Revised Statutes

§4256. Coverage for medically necessary infant formula

(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. [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.
[ 2007, c. 695, Pt. C, §16 (RAL) .]
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.
[ 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; [2007, c. 695, Pt. C, §16 (RAL).]
B. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis; [2007, c. 695, Pt. C, §16 (RAL).]
C. A history of anaphylaxis; [2007, c. 695, Pt. C, §16 (RAL).]
D. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies; [2007, c. 695, Pt. C, §16 (RAL).]
E. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider; [2007, c. 695, Pt. C, §16 (RAL).]
F. Cystic fibrosis; or [2007, c. 695, Pt. C, §16 (RAL).]
G. Malabsorption of cow milk-based or soy milk-based infant formula. [2007, c. 695, Pt. C, §16 (RAL).]
[ 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.
[ 2007, c. 695, Pt. C, §16 (RAL) .]
SECTION HISTORY
2007, c. 695, Pt. C, §16 (RAL).

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