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 medical foods
6insurance coverage and, for cost-sharing provisions, for<- 
7regulations and for applicability<-.

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

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

<-13Section 1. The title and sections 4, 6, 8 and 9 of the act
14of December 20, 1996 (P.L.1492, No.191), known as the Medical
15Foods Insurance 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

1phenylketonuria and [related] other disorders.

2Section 4. Medical foods insurance coverage.

3(a) Nutritional supplements.--Except as provided in section
47, any health insurance policy which is delivered, issued for
5delivery, renewed, extended or modified in this Commonwealth by
6any health care insurer shall provide that the health insurance
7benefits applicable under the policy include coverage for the
8cost of nutritional supplements (formulas) as medically
9necessary for the therapeutic treatment of phenylketonuria,
10branched-chain ketonuria, galactosemia and homocystinuria as
11administered under the direction of a physician.

12(b) Amino acid-based elemental medical formula.--Except as 
13provided in section 7, any health insurance policy which is 
14delivered, issued for delivery, renewed, extended or modified in 
15this Commonwealth by any health care insurer shall provide that 
16the health insurance benefits applicable under the policy 
17include coverage for infants and children for the <-usual and 
18customary cost of amino acid-based elemental medical formula 
<-19prescribed ordered by a physician <-as medically necessary and 
20administered orally or enterally for IgE and non-IgE <-mediated 
21food protein allergies, food protein-induced enterocolitis 
22syndrome, eosinophilic disorders and short-bowel syndrome. <-An 
23amino acid-based elemental formula covered under this section is 
24a formula made of 100% free amino acids as the protein source.

25Section 6. Cost-sharing provisions.

26(a) Applicability.--Benefits for nutritional supplements
27(formulas) as medically necessary for the therapeutic treatment
28of phenylketonuria, branched-chain ketonuria, galactosemia and
29homocystinuria as administered under the direction of a
30physician shall be subject to copayment and coinsurance

1provisions of a health insurance policy to the extent that other
2medical services covered by the policy are subject to those
3provisions.

4(a.1) Amino acid-based elemental medical formula.--Benefits
5for amino acid-based elemental medical formula <-prescribed
<-6ordered by a physician as medically necessary for <-IgE and non-
7IgE mediated food protein allergies, food protein-induced
8enterocolitis syndrome, eosinophilic disorders and short-bowel
9syndrome shall be subject to copayment and coinsurance
10provisions of a health insurance policy to the extent that other
11medical services covered by the policy are subject to those
12provisions.

13(b) Exemption.--Benefits for nutritional supplements
14(formulas) as medically necessary for the therapeutic treatment
15of phenylketonuria, branched-chain ketonuria, galactosemia and
16homocystinuria as administered under the direction of a
17physician shall be exempt from deductible provisions in a health
18insurance policy. This exemption must be explicitly provided for
19in the policy.

<-20Section 8. Regulations.

21The Department of Health and the Insurance Department [shall]
22may promulgate regulations as necessary and appropriate to
23implement this act.

24Section 9. Applicability.

25[This act shall apply to all insurance policies, subscriber
26contracts and group insurance certificates issued under any
27group master policy delivered or issued for delivery on or after
28the effective date of this act. This act shall also apply to all
29renewals of contracts on any renewal date which is on or after
30the effective date of this act.] This act shall apply as
 

1follows:

2(1) For health insurance policies for which either rates
3or forms are required to be filed with the Insurance
4Department or the Federal Government, this act shall apply to
5any policy for which a form or rate is first filed on or
6after the effective date of this section.

7(2) For health insurance policies for which neither
8rates nor forms are required to be filed with the Insurance
9Department or the Federal Government, this act shall apply to
10any policy issued or renewed on or after 180 days after the
11effective date of this section.

12Section 2. This act shall take effect in 180 days.