{"data":{"id":"us-me/24-a-m.r.s.-4256","jurisdiction":"us-me","citation":"24-A M.R.S. §4256","heading":"Coverage for medically necessary infant formula","body":"(REALLOCATED FROM TITLE 24-A, SECTION 4254)\nAll individual and group health maintenance organization policies, contracts and certificates must provide coverage for amino acid-based elemental infant formula for children 2 years of age and under in accordance with this section.\n1.  Determination of medical necessity.  Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has submitted documentation that the amino acid-based elemental infant formula is medically necessary health care as defined in section 4301‑A, subsection 10‑A, that the amino acid-based elemental infant formula is the predominant source of nutritional intake at a rate of 50% or greater and that other commercial infant formulas, including cow milk-based and soy milk-based formulas have been tried and have failed or are contraindicated. A licensed physician may be required to confirm and document ongoing medical necessity at least annually.\n2.  Method of delivery.  Coverage for amino acid-based elemental infant formula must be provided without regard to the method of delivery of the formula.\n3.  Required diagnosis.  Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has diagnosed and through medical evaluation has documented one of the following conditions:\nA.  Symptomatic allergic colitis or proctitis;\nB.  Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis;\nC.  A history of anaphylaxis;\nD.  Gastroesophageal reflux disease that is nonresponsive to standard medical therapies;\nE.  Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider;\nF.  Cystic fibrosis; or\nG.  Malabsorption of cow milk-based or soy milk-based infant formula.\n4.  Health savings accounts.  Coverage for amino acid-based elemental infant formula under a health insurance policy, contract or certificate issued in connection with a health savings account as authorized under Title XII of the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003 may be subject to the same deductible and out-of-pocket limits that apply to overall benefits under the policy, contract or certificate.","path":["TITLE 24-A: MAINE INSURANCE CODE","CHAPTER 56: HEALTH MAINTENANCE ORGANIZATIONS"],"source_url":"https://legislature.maine.gov/statutes/24-A/title24-Asec4256.html","current_through":"October 1, 2025","vintage":"","retrieved_at":"2026-09-04T15:12:33Z","sha256":"133253408cc5d74ad1c5d3b955a7067c66397331390e08b20cabe42e131df8cc","source_id":"us-me","stale":false,"prev":"us-me/24-a-m.r.s.-4255","next":"us-me/24-a-m.r.s.-4257"},"notice":"GroundRules: Original legal text. Not legal advice."}