State Mandates - How Mandates Impact Medical Food Insurance Coverage


Posted 12.10.15 | Nutrition Specialist

What is a state mandate?

State mandates are bills passed into law, which require insurance companies operating in a state to cover the use of elemental formula (i.e. Neocate products), when medically necessary. Without these state mandates, many in need of elemental formulas as their sole source of nutrition would bear 100% of the costs out of pocket.  In the image below (in purple shading) are states that have passed elemental formula mandates or have enacted “insurance agreements”, partnerships insurance companies have made to cover Neocate in a particular state:

Map of Mandated States 2015

Although states enact mandates, one caveat is that these only require insurance plans that are considered fully-funded to cover elemental formula, such as Neocate. A fully-funded plan is the type of insurance plan in which a member typically pays a set premium, and your insurance company bears the financial risk of paying each insurance claim.

If you have a self-funded plan, where your employer bears all risks and costs of paying insurance claims, it is not covered under state mandate laws.

What do I need to know as a parent?

If you live in a mandated state and your plan is designated as fully-funded, you should have Neocate coverage.

If, however, you are in a mandated state and your plan is self-funded, or you reside in a state with no mandate, know there is still hope for coverage. You may be able to gain coverage with assistance from Nutricia’s Navigator reimbursement support services. Our Navigator Team assists families in gaining formula coverage and will educate you, as a parent, on the means in which affordable elemental formula may be available in these dire situations. 

To learn more about the Navigator service, please call 1-800-365-7354 option 8, extension 1200or email the Navigator team at NutricaNavigator@nutricia.com.

If you are looking to gain legislative support to have your state become mandated, please visit the website for Children’s MAGIC, an organization committed to expanding healthcare coverage for elemental formula nationally, at http://www.childrensmagic.org or call at 1-866-501-2404.

- Raymond Gayle

About the Author: Raymond Gale is a Reimbursement Manager, health policy strategist and contributing writer for Nutricia North America

 

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Food Allergy Living is a resource for parents of children with food allergies, brought to you by Nutricia, the makers of Neocate. For more in-depth information about our purpose & authors, see our About Food Allergy Living page.