NEW JERSEY

INDIVIDUAL HEALTH COVERAGE PROGRAM

20 West State Street, 10th Floor

PO Box 325

Trenton, NJ 08625

Phone: 609-633-1882

Fax: 609-633-2030

 

ADVISORY BULLETIN

98-IHC-03

 

August 7, 1998

 

To: IHC Program Member Carriers

From: Ellen F. DeRosa, Deputy Executive Director

Re: Amendments to the Standard Health Benefits Plans

 

The Individual Health Coverage Program Board readopted its regulations set forth at N.J.A.C. 11:20-1.1 et seq. Included in the readoption were the standard health benefits plans. A copy of the adoption text as filed with the Office of Administrative Law was provided to your company under separate cover. The effective date of the adoption, including the changes to the standard health benefits plans, is August 7, 1998.

 

Carriers may modify the text of the standard plans to comply with the amendment to cover food and food products for inherited metabolic diseases in one of the following ways:

  1. Incorporate the revised text in the standard plans;

  2. Use the Compliance and Variability Rider (N.J.A.C. 11:20 Appendix Exhibit S) to amend the standard plans to conform with the adopted amendments; or

  3. A combination of incorporating the revised text in the standard plans and use of the Compliance and Variability Rider.

 

Carriers that elect to use the Compliance and Variability Rider must use the attached text to address the changes to the standard health benefits plans. The introductory and concluding text on the rider must be consistent with N.J.A.C. 11:20 Exhibit S.

 

To the extent that these forms changes necessitate a rate filing, please make the appropriate rate filing pursuant to N.J.A.C. 11:20-6.

 

If you have any questions, feel free to contact me.

 

 

Rider Text To be included on the Compliance and Variability Rider (Exhibit S) to amend Standard Individual Health Benefits Plan A

 

Section: COVERED CHARGES

Subsection: New

 

The following provision is added to the COVERED CHARGES section of the Policy.

 

Food and Food Products for Inherited Metabolic Diseases: [Carrier] covers charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by the Covered Person’s Practitioner.

 

For the purpose of this benefit:

"inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law;

"low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and

"medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.

 

Section: EXCLUSIONS

Subsection: Non-Prescription Drugs or Supplies

 

The exclusion for non-prescription drugs or supplies is deleted and replaced with the following exclusion:

 

Non-Prescription Drugs or supplies, except:

  1. insulin, needles and syringes; and
  2. as stated in this Policy for food and food products for inherited metabolic diseases.

 

Rider Text To be included on the Compliance and Variability Rider (Exhibit S) to amend Standard Individual Health Benefits Plans B, C, D and E.

 

Section: COVERED CHARGES

Subsection: New

 

The following provision is added to the COVERED CHARGES section of the Policy.

 

Food and Food Products for Inherited Metabolic Diseases: [Carrier] covers charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by the Covered Person’s Practitioner.

 

 

For the purpose of this benefit:

"inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law;

"low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and

"medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.

 

Section: EXCLUSIONS

Subsection: Non-Prescription Drugs or Supplies

 

The exclusion for non-prescription drugs or supplies is deleted and replaced with the following exclusion:

 

Non - Prescription Drugs or supplies, except:

  1. insulin, needles and syringes, glucose test strips and lancets;
  2. colostomy bags, belts, and irrigators; and
  3. as stated in this Policy for food and food products for inherited metabolic diseases.

 

Rider Text To be included on the Compliance and Variability Rider (Exhibit S) to amend the Standard Individual Health Benefits Plan HMO.

 

Section: COVERED CHARGES AND SUPPLIES

Subsection: Outpatient Benefits

 

The following item 11 is added to the Outpatient Benefits.

 

  1. Food and Food Products for Inherited Metabolic Diseases: We cover charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by Your Practitioner.

 

For the purpose of this benefit:

"inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law;

"low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and

"medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.

 

 

Section: EXCLUSIONS

Subsection: Non-Prescription Drugs or Supplies

 

The exclusion for non-prescription drugs or supplies is deleted and replaced with the following exclusion:

 

Non - Prescription Drugs or supplies, except:

  1. insulin, needles and syringes, glucose test strips and lancets;
  2. colostomy bags, belts, and irrigators; and
  3. as stated in this Contract for food and food products for inherited metabolic diseases.