Health Plan Clarifies Policy On Infant Formulas

Attorney General Spitzer today announced that Aetna will no longer deny coverage for medically necessary formulas for infants and other patients with illnesses that cause malnutrition and other disabling conditions.

"Health insurance companies must ensure that they do not improperly deny coverage to New Yorkers," said Attorney General Spitzer. "Aetna is doing right by correcting its internal procedures to ensure that it will not deny coverage to its members for critical medically necessary nutritional supplements."

Before the Attorney General's investigation, Aetna denied claims for medically necessary enteral formulas, such as Neocate, if they were administered orally. This policy was based on Aetna’s interpretation that "enteral" was limited to tube-fed nutrition. Aetna’s practice was a violation of state insurance law which mandates coverage for such supplements.

The agreement with Aetna means that its 485,000 members in New York will now be able to obtain the coverage for both orally administered and tube-fed enteral formulas, as mandated by state law.

An enteral formula is designed to provide nutrition to people who would otherwise be unable to digest food products or supplements due to allergies or disease.

The investigation of Aetna’s practices was sparked by the complaint of a Rockland County man who was denied coverage for prescribed Neocate nutritional supplements for his infant son who was severely allergic to cow's milk and soy protein.

Under the agrement with the Attorney General's Office, Aetna will:

  • Cease denying enteral formula claims on grounds that the particular enteral formula is not tube fed;
  • Review its claims records for the past five years and reimburse consumers who were improperly denied coverage for enteral formulas; and
  • Post instructions on its website and in newspapers for members who may have been denied enteral formula coverage to make claims.

In addition, Aetna will pay $25,000 to the state to cover costs of the investigation.

This case is the latest in a series of enforcement actions by the Attorney General's Health Care Bureau under the state insurance law, to vindicate the rights of New Yorkers to receive appropriate coverage for services and products ordered by their doctor.

The case was handled by Assistant Attorney General John Powell under the direction of Joe Baker, chief of the Attorney General's Health Care Bureau and Troy Oechsner, deputy chief of the Health Care Bureau. The original complaint was received through the Health Care Bureau’s Consumer Helpline.


For Adobe PDF files you can download Adobe Reader from Adobe Systems.