Chapter 38E. Medically Necessary Foods Coverage.
§ 31–3871. Medically necessary foods.
(a) A health benefits plan issued, renewed, extended, or modified in the District by a health insurer after December 31, 2022, shall provide coverage for the cost of medically necessary food ordered as necessary by a provider for the following diseases or conditions:
(1) Inflammatory bowel disease, including Crohn's disease, ulcerative colitis, and indeterminate colitis;
(2) Gastroesophageal reflux disease that is nonresponsive to standard medical therapies;
(3) Immunoglobulin E- and non-Immunoglobulin E-mediated allergies to food proteins;
(4) Food protein-induced enterocolitis syndrome;
(5) Eosinophilic disorders, including eosinophilic esophagitis, eosinophilic gastroenteritis, eosinophilic colitis, and post-transplant eosinophilic disorders;
(6) Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract, including short bowel syndrome and chronic intestinal pseudo-obstruction;
(7) Malabsorption due to liver or pancreatic disease;
(8) Inherited metabolic disorders; and
(9) Any other diseases or conditions as determined by the Mayor through rulemaking.
(b) The coverage provided under this section shall not be more restrictive than or separate from coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors.
(c) The Mayor, pursuant to subchapter I of Chapter 5 of Title 2, may issue rules to implement the provisions of this chapter.
(d) For the purposes of this section, the term:
(1) "Health benefits plan" means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer welfare arrangement, or plan provided by another benefit arrangement. The term "health benefit plan" does not include accident only, credit, or disability insurance; coverage of Medicare services or federal employee health plans, pursuant to contracts with the United States government; Medicare supplemental or long-term care insurance; dental only or vision only insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(2) "Health insurer" means a person that provides one or more health benefit plans or insurance in the District, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Department of Insurance, Securities, and Banking.
(3) "Medically necessary food" means food, including a low-protein modified food product or an amino acid preparation product, a modified fat preparation product, or a nutritional formula that is specially formulated and processed for the partial or exclusive feeding of an individual by means of oral intake or enteral feeding by tube, and intended for dietary management of an individual who, because of therapeutic or chronic medical needs, has limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foodstuffs or certain nutrients or who has other specially medically determined nutrient requirements, the dietary management of which cannot be achieved by modification of the normal diet alone.
