23-79-703. Health insurance coverage for medically necessary foods — Definition.

23-79-703. Health insurance coverage for medically necessary foods — Definition. (a) As used in this section, “medical disorder requiring specialized nutrients or formulas” means the following inherited metabolic disorders involving a failure to properly metabolize certain nutrients: (1) Nitrogen metabolism disorder; (2) Phenylketonuria; (3) Maple syrup urine disease; (4) Homocystinuria; (5) Citrullinemia; (6) Argininosuccinic acidemia; (7) Tyrosinemia, type 1; (8) Very-long-chain acyl-CoA dehydrogenase deficiency; (9) Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency; (10) Trifunctional protein deficiency; (11) Glutaric acidemia, type 1; (12) 3-methylcrotonyl CoA carboxylase deficiency; (13) Propionic acidemia; (14) Methylmalonic acidemia due to mutase deficiency; (15) Methlmalonic acidemia due to cobalamin A,B defect; (16) Isovaleric acidemia; (17) Ornithine transcarbamylase deficiency; (18) Non-ketotic hyperglycinemia; (19) Glycogen storage diseases; (20) Disorders of creatine metabolism; (21) Malonic aciduria; (22) Carnitine palmitoyl transferase deficiency type II; (23) Glutaric aciduria type II; and (24) Sulfite oxidase deficiency. (b)(1) A health plan issued, delivered, amended, or modified in this state after January 1, 2018, shall provide the minimum benefits under subsection (c) of this section for medical foods, including without limitation: (A) Low-protein modified food products; (B) Amino-acid-based elemental formulas; (C) Extensively hydrolyzed protein formulas; (D) Formulas with modified vitamin or mineral content; and (E) Modified nutrient content formulas. (2)(A) The products and formulas listed in subdivision (b)(1) of this section shall be covered by a health plan regardless of delivery method, whether enteral or oral, or sole source or supplemental, or the age of the covered person, for the treatment of a covered person with a medical disorder requiring specialized nutrients or formulas if: (i) Either of the following occurs: (a) The medical food or low-protein modified food products, regardless of delivery method, are prescribed by a healthcare provider licensed under § 17-95-401 et seq. as medically necessary; or (b) A healthcare provider licensed under § 17-95-401 et seq. issues a written order stating that a medical food is medically necessary for the therapeutic treatment of a medical disorder requiring specialized nutrients or formulas as described in subdivision (b)(1) of this section; and (ii) The product or formula is administered under the direction of a licensed healthcare practitioner under § 17-95-401 et seq. and shall only be administered under the direction of a clinical geneticist and a registered dietitian. (B) As used in subdivision (b)(2)(A) of this section, a “healthcare provider” does not include a nurse practitioner or physician's assistant. (3) To be covered by a health plan, treatment of a medical disorder requiring specialized nutrients or formulas shall be: (A) Derived from evidence-based practice guidelines; and (B) Efficacious. (c)(1) A health insurance policy, contract, certificate, or healthcare plan issued in this state by an insurance company, hospital medical service corporation, health maintenance organization, or a self-funded or self-insured governmental plan, whether an individual or group policy, contract, certificate, or healthcare plan, that covers the insured and the insured's family shall provide coverage and reimbursement for the treatment of a medical disorder requiring specialized nutrients or formulas in accordance with subsection (b) of this section. (2) Benefits provided under the Arkansas Medicaid Program or coverage limited to expenses from an accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income, or other limited benefit health insurance policy or plan is exempt from the requirement of subdivision (c)(1) of this section. (3) The benefit provided under subdivision (c)(1) of this section may be subject to a deductible, copayments, coinsurance, or other patient cost-sharing amounts required by the health plan. (d) If the cost of the products or formulas described in subdivision (b)(1) of this section for a covered person exceeds the income tax credit of two thousand four hundred dollars ($2,400) per year per covered person allowed under § 23-79-702 and the covered person cannot afford insurance coverage for treatment of a medical disorder requiring specialized nutrients or formulas as described in subdivision (b)(1) of this section, the Department of Health shall reimburse the healthcare provider up to one thousand dollars ($1,000) per covered person from any funds appropriated for the required healthcare service, including screening, diagnostic, and treatment services.