AN ACT

 

1Amending the act of December 20, 1996 (P.L.1492, No.191),
2entitled "An act providing for certain health insurance
3policies to cover the cost of formulas necessary for the
4treatment of phenylketonuria and related disorders," amending
5the title of the act; and further providing <-for declaration 
6of policy, for medical foods insurance coverage<-, and for
7cost-sharing provisions <-and for exemption.

8The General Assembly of the Commonwealth of Pennsylvania
9hereby enacts as follows:

<-10Section 1. The title and sections 2, 4, 6 and 7 of the act
11of December 20, 1996 (P.L.1492, No.191), known as the Medical
12Foods Insurance Coverage Act, are amended to read:

<-13Section 1. The title and sections 4 and 6 of the act of
14December 20, 1996 (P.L.1492, No.191), known as the Medical Foods
15Insurance Coverage Act, are amended to read:

16AN ACT

17Providing for certain health insurance policies to cover the
18cost of formulas necessary for the treatment of
19phenylketonuria and [related] other disorders. <-and food
 

1related allergic disorders.

2Section 2. Declaration of policy.

3The General Assembly finds and declares as follows:

4(1) Phenylketonuria (PKU), branched-chain ketonuria,
5galactosemia and homocystinuria are aminoacidopathies that
6are rare hereditary genetic metabolic disorders.

7(2) Lacking in these aminoacidopathies is the body's
8ability to process or metabolize amino acids, and, if left
9untreated or without proper therapeutic management, these
10disorders cause severe mental retardation and chronic
11physical disabilities.

12(3) The only form of treatment is by restricting food
13intake in order to remove the problem amino acids, which are
14necessary in the diet, and then replenishing them in
15carefully controlled measured amounts of a nutritional food
16substitute.

17(4) In an attempt to encourage the development of new
18products, increase availability and reduce cost, formulas
19were removed from the Federal prescription list and
20reclassified as medical foods. An unfortunate side effect has
21been the reluctance of many insurance companies to cover the
22cost of these formulas. In instances where coverage is
23provided, it is random and subject to inconsistent
24interpretation.

25(5) The intent of this legislation is not to require
26insurance coverage for normal food products used in dietary
27management of these disorders, but to provide for such
28coverage of formulas that are equivalent to a prescription
29drug medically necessary for the therapeutic treatment and
30dietary management of such rare hereditary genetic metabolic

1and food-related allergic disorders, and administered under
2the direction of a physician.

3(6) In recognition by the General Assembly that such
4formulas are medically necessary and critical to the well-
5being of individuals afflicted with rare hereditary genetic
6metabolic and food-related allergic disorders, it shall be
7required that health insurance policies issued in this
8Commonwealth shall include such coverage.

9Section 4. Medical foods insurance coverage.

<-10(a) Nutritional supplements.--Except as provided in section
117, any health insurance policy which is delivered, issued for
12delivery, renewed, extended or modified in this Commonwealth by
13any health care insurer shall provide that the health insurance
14benefits applicable under the policy include coverage for the
15cost of nutritional supplements (formulas) as medically
16necessary for the therapeutic treatment of phenylketonuria,
17branched-chain ketonuria, galactosemia [and], homocystinuria<-, 
18IgE and Non-IgE mediated food protein allergies, food protein-
19induced enterocolitis syndrome, eosinophilic disorders and 
20short-bowel syndrome as administered under the direction of a
21physician.

<-22(b) Amino acid-based elemental medical formula.--Except as 
23provided in section 7, any health insurance policy which is 
24delivered, issued for delivery, renewed, extended or modified in 
25this Commonwealth by any health care insurer shall provide that 
26the health insurance benefits applicable under the policy 
27include coverage for infants and children for the cost of amino 
28acid-based elemental medical formula prescribed by a physician 
29and administered orally or enterally for IgE and non-IgE 
30mediated food protein allergies, food protein-induced
 

1enterocolitis syndrome, eosinophilic disorders and short-bowel 
2syndrome.

3Section 6. Cost-sharing provisions.

4(a) Applicability.--Benefits for nutritional supplements
5(formulas) as medically necessary for the therapeutic treatment
6of phenylketonuria, branched-chain ketonuria, galactosemia
7[and], homocystinuria <-and food-related allergic disorders as
8administered under the direction of a physician shall be subject
9to copayment and coinsurance provisions of a health insurance
10policy to the extent that other medical services covered by the
11policy are subject to those provisions.

<-12(a.1) Amino acid-based elemental medical formula.--Benefits
13for amino acid-based elemental medical formula prescribed by a
14physician for IgE and non-IgE mediated food protein allergies,
15food protein-induced enterocolitis syndrome, eosinophilic
16disorders and short-bowel syndrome shall be subject to copayment
17and coinsurance provisions of a health insurance policy to the
18extent that other medical services covered by the policy are
19subject to those provisions.

20(b) Exemption.--Benefits for nutritional supplements
21(formulas) as medically necessary for the therapeutic treatment
22of phenylketonuria, branched-chain ketonuria, galactosemia and
23homocystinuria as administered under the direction of a
24physician shall be exempt from deductible provisions in a health
25insurance policy. This exemption must be explicitly provided for
26in the policy.

<-27Section 7. Exemption.

28Notwithstanding sections 4 and 5, this act shall not be
29construed to require a health insurance policy to include
30coverage for nutritional supplements (formulas) as medically

1necessary for the therapeutic treatment of phenylketonuria,
2branched-chain ketonuria, galactosemia [and], homocystinuria and
3food-related allergic disorders as administered under the
4direction of a physician for an individual who is a resident of
5this Commonwealth if all of the following apply:

6(1) The individual is employed outside this
7Commonwealth.

8(2) The individual's employer maintains a health
9insurance policy for the individual as an employment benefit.

10Section 2. This act shall take effect in 180 days.