Health Plan Clarifies Policy On Nutrition Supplements

Attorney General Spitzer today announced that Empire BlueCross BlueShield will change its computer system to ensure that it does not inappropriately deny coverage for medically necessary nutritional supplements for infants and other patients with illnesses that cause malnutrition and other disabling conditions.

Before the Attorney General's action, BlueCross BlueShield's pharmacy benefit manager, Advance PCS, of Irving, Texas, relied on a computer program that automatically denied medically necessary nutritional supplements like Neocate, Ensure and PediaSure as non-covered, over-the-counter products. This practice violates state insurance law which mandates coverage for such supplements.

The agreement with Empire BlueCross BlueShield means that its members will be able to obtain the coverage for nutritional supplements coverage that state law mandates.

The review of BlueCross BlueShield's practices was sparked by the complaint of a Westchester County woman who was denied coverage for prescribed nutritional supplements for her baby who was severely allergic to cow's milk and soy protein.

"Health insurance companies must carefully monitor their computer systems to ensure that they do not improperly deny coverage to New Yorkers," said Attorney General Spitzer. "BlueCross BlueShield is doing right by correcting its computer program to ensure that it will not deny coverage to its members for critical medically necessary nutritional supplements."

Blocking coverage of medically necessary nutritional supplements is a violation of state insurance law which specifically directs health plans to cover their cost regardless of whether they are available over the counter.

The agreement with the Attorney General's Office calls for BlueCross BlueShield to:

  • Direct Advance PCS to modify its computer programming to accurately reflect New York state law;

  • Review its records to find and rectify cases of previously denied coverage for nutritional supplements;

  • Post instructions on its website and in its newsletter for members who may have been denied coverage for nutritional supplements to make claims; and,

  • Train its staff about New York's law mandating coverage for nutritional supplements.

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

The settlement takes effect January 2, 2004.

Empire BlueCross BlueShield has some 690,000 members in New York State.

This case is the latest in a series of actions by the Attorney General's Health Care Bureau to enforce state insurance law to ensure that New Yorkers have access to covered services and products to which they are entitled and which their doctor has ordered. Most of the cases involve reviewing the circumstances under which health plans deny coverage to members.

The case was handled by Deputy Bureau Chief Sandra Jefferson Grannum under the direction of Joe Baker, chief of the Attorney General's Health Care Bureau.


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