PRINTER'S NO. 3052
No. 2435 Session of 1994
INTRODUCED BY KENNEY, DeLUCA, OLASZ, HENNESSEY, YANDRISEVITS,
FICHTER, LAUB, SATHER, COY, MELIO, JOSEPHS, SAURMAN,
E. Z. TAYLOR, J. TAYLOR, STEELMAN AND CURRY, JANUARY 4, 1994
REFERRED TO COMMITTEE ON INSURANCE, JANUARY 4, 1994
AN ACT
1 Providing for certain health insurance policies to cover the
2 cost of formulas necessary for the treatment of
3 phenylketonuria and related disorders.
4 The General Assembly of the Commonwealth of Pennsylvania
5 hereby enacts as follows:
6 Section 1. Short title.
7 This act shall be known and may be cited as the Medical Foods
8 Insurance Coverage Act.
9 Section 2. Declaration of policy.
10 The General Assembly finds and declares as follows:
11 (1) Phenylketonuria (PKU), branched-chain ketonuria,
12 galactosemia and homocystinuria are aminoacidopathies that
13 are rare hereditary genetic metabolic disorders.
14 (2) Lacking in these aminoacidopathies is the body's
15 ability to process or metabolize amino acids, and, if left
16 untreated or without proper therapeutic management, these
17 disorders cause severe mental retardation and chronic
18 physical disabilities.
1 (3) The only form of treatment is by restricting food
2 intake in order to remove the problem amino acids, which are
3 necessary in the diet, and then replenishing them in
4 carefully controlled measured amounts of a nutritional food
5 substitute.
6 (4) In an attempt to encourage the development of new
7 products, increase availability and reduce cost, formulas
8 were removed from the Federal prescription list and
9 reclassified as medical foods. An unfortunate side effect has
10 been the reluctance of many insurance companies to cover the
11 cost of these formulas. In instances where coverage is
12 provided, it is random and subject to inconsistent
13 interpretation.
14 (5) The intent of this legislation is not to require
15 insurance coverage for normal food products used in dietary
16 management of these disorders, but to provide for such
17 coverage of formulas that are equivalent to a prescription
18 drug, medically necessary for the therapeutic treatment of
19 such rare hereditary genetic metabolic disorders and
20 administered under the direction of a physician.
21 (6) In recognition by the General Assembly that such
22 formulas are medically necessary and critical to the well-
23 being of individuals afflicted with rare hereditary genetic
24 metabolic disorders, it shall be required that health
25 insurance policies issued in this Commonwealth shall include
26 such coverage.
27 Section 3. Definitions.
28 The following words and phrases when used in this act shall
29 have the meanings given to them in this section unless the
30 context clearly indicates otherwise:
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1 "Health insurance policy." Except for specified disease and
2 accident only policies, the term shall mean any group health
3 insurance policy, contract or plan or any individual policy,
4 contract or plan with coverage for prescription drugs which
5 provides medical coverage on an expense-incurred, service or
6 prepaid basis. The term includes the following:
7 (1) A health insurance policy or contract issued by a
8 nonprofit corporation subject to 40 Pa.C.S. Chs. 61 (relating
9 to hospital plan corporations) and 63 (relating to
10 professional health services plan corporations) and the act
11 of December 14, 1992 (P.L.835, No.134), known as the
12 Fraternal Benefit Societies Code.
13 (2) A health service plan operating under the act of
14 December 29, 1972 (P.L.1701, No.364), known as the Health
15 Maintenance Organization Act.
16 Section 4. Medical foods insurance coverage.
17 Except as provided in section 7, any health insurance policy
18 which is delivered, issued for delivery, renewed, extended or
19 modified in this Commonwealth by any health care insurer shall
20 provide that the health insurance benefits applicable under the
21 policy include coverage for the cost of nutritional supplements
22 (formulas) as medically necessary for the therapeutic treatment
23 of phenylketonuria, branched-chain ketonuria, galactosemia and
24 homocystinuria as administered under the direction of a
25 physician.
26 Section 5. Delivery of policy.
27 Except as provided in section 7, if a health insurance policy
28 provides coverage or benefits to a resident of this
29 Commonwealth, it shall be deemed to be delivered in this
30 Commonwealth within the meaning of this act, regardless of
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1 whether the health care insurer issuing or delivering the policy
2 is located within or outside this Commonwealth.
3 Section 6. Cost-sharing provisions.
4 (a) Applicability.--Benefits for nutritional supplements
5 (formulas) as medically necessary for the therapeutic treatment
6 of phenylketonuria, branched-chain ketonuria, galactosemia and
7 homocystinuria as administered under the direction of a
8 physician shall be subject to copayment and coinsurance
9 provisions of a health insurance policy to the extent that other
10 medical services covered by the policy are subject to those
11 provisions.
12 (b) Exemption.--Benefits for nutritional supplements
13 (formulas) as medically necessary for the therapeutic treatment
14 of phenylketonuria, branched-chain ketonuria, galactosemia and
15 homocystinuria as administered under the direction of a
16 physician shall be exempt from deductible or dollar limit
17 provisions in a health insurance policy. This exemption must be
18 explicitly provided for in the policy.
19 Section 7. Exemption.
20 Notwithstanding sections 4 and 5, this act shall not be
21 construed to require a health insurance policy to include
22 coverage for nutritional supplements (formulas) as medically
23 necessary for the therapeutic treatment of phenylketonuria,
24 branched-chain ketonuria, galactosemia and homocystinuria as
25 administered under the direction of a physician for an
26 individual who is a resident of this Commonwealth if all of the
27 following apply:
28 (1) The individual is employed outside this
29 Commonwealth.
30 (2) The individual's employer maintains a health
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1 insurance policy for the individual as an employment benefit.
2 Section 8. Regulations.
3 The Department of Health and the Insurance Department shall
4 promulgate regulations to implement this act.
5 Section 9. Applicability.
6 This act shall apply to all insurance policies, subscriber
7 contracts and group insurance certificates issued under any
8 group master policy, delivered or issued for delivery on or
9 after the effective date of this act. This act shall also apply
10 to all renewals of contracts on any renewal date which is on or
11 after the effective date of this act.
12 Section 10. Effective date.
13 This act shall take effect in six months.
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