PRINTER'S NO. 1154
No. 979 Session of 2003
INTRODUCED BY MICOZZIE, KENNEY, BUXTON, HENNESSEY, MELIO,
BELARDI, BUNT, CAPPELLI, CREIGHTON, CURRY, DeWEESE, FLEAGLE,
GEIST, HARHAI, LaGROTTA, McILHATTAN, NAILOR, SHANER, SOLOBAY,
STERN, E. Z. TAYLOR, WASHINGTON AND YOUNGBLOOD,
MARCH 26, 2003
REFERRED TO COMMITTEE ON INSURANCE, MARCH 26, 2003
AN ACT
1 Amending the act of December 20, 1996 (P.L.1492, No.191),
2 entitled "An act providing for certain health insurance
3 policies to cover the cost of formulas necessary for the
4 treatment of phenylketonuria and related disorders," further
5 defining "health insurance policy"; and providing for low-
6 protein modified food products.
7 The General Assembly of the Commonwealth of Pennsylvania
8 hereby enacts as follows:
9 Section 1. Sections 2, 3, 4, 6 and 7 of the act of December
10 20, 1996 (P.L.1492, No.191), known as the Medical Foods
11 Insurance Coverage Act, are amended to read:
12 Section 2. Declaration of policy.
13 The General Assembly finds and declares as follows:
14 (1) Phenylketonuria (PKU), branched-chain ketonuria,
15 galactosemia and homocystinuria are aminoacidopathies that
16 are rare hereditary genetic metabolic disorders.
17 (2) Lacking in these aminoacidopathies is the body's
18 ability to process or metabolize amino acids, and, if left
1 untreated or without proper therapeutic management, these
2 disorders cause severe mental retardation and chronic
3 physical disabilities.
4 (3) The only form of treatment is by restricting food
5 intake in order to remove the problem amino acids, which are
6 necessary in the diet, and then replenishing them in
7 carefully controlled measured amounts of a nutritional food
8 substitute.
9 (4) In an attempt to encourage the development of new
10 products, increase availability and reduce cost, formulas
11 were removed from the Federal prescription list and
12 reclassified as medical foods. An unfortunate side effect has
13 been the reluctance of many insurance companies to cover the
14 cost of these formulas. In instances where coverage is
15 provided, it is random and subject to inconsistent
16 interpretation.
17 (5) The intent of this legislation is not to require
18 insurance coverage for [normal food products] natural food
19 products that are naturally low in protein which are used in
20 dietary management of these disorders, but to provide for
21 such coverage of formulas that are equivalent to a
22 prescription drug and low-protein modified food products
23 medically necessary for the therapeutic treatment of such
24 rare hereditary genetic metabolic disorders and administered
25 under the direction of a physician.
26 (6) In recognition by the General Assembly that such
27 formulas and low-protein modified food products are medically
28 necessary and critical to the well-being of individuals
29 afflicted with rare hereditary genetic metabolic disorders,
30 it shall be required that health insurance policies issued in
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1 this Commonwealth shall include such coverage.
2 Section 3. Definitions.
3 The following words and phrases when used in this act shall
4 have the meanings given to them in this section unless the
5 context clearly indicates otherwise:
6 "Health insurance policy." Except for specified disease and
7 accident-only policies, the term shall mean any group health
8 insurance policy, contract or plan or any individual policy,
9 contract or plan [with coverage for prescription drugs] which
10 provides medical coverage on an expense-incurred, service or
11 prepaid basis. The term includes the following:
12 (1) A health insurance policy or contract issued by a
13 nonprofit corporation subject to 40 Pa.C.S. Chs. 61 (relating
14 to hospital plan corporations) and 63 (relating to
15 professional health services plan corporations) and [the act
16 of December 14, 1992 (P.L.835, No.134), known as the
17 Fraternal Benefit Societies Code.] Article 24 of the act of
18 May 17, 1921 (P.L.582, No.294), known as The Insurance
19 Company Law of 1921.
20 (2) A health service plan operating under the act of
21 December 29, 1972 (P.L.1701, No.364), known as the Health
22 Maintenance Organization Act.
23 "Low-protein modified food product." A food product that is
24 specially formulated to have less than one gram of protein per
25 serving, and intended to be administered by and used under the
26 direction of a physician for the therapeutic and dietary
27 treatment of phenylketonuria, branched-chain ketonuria,
28 galactosemia and homocystinuria. The term does not include a
29 natural food that is naturally low in protein.
30 Section 4. Medical foods insurance coverage.
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1 (a) General rule.--Except as provided in section 7, any
2 health insurance policy which is delivered, issued for delivery,
3 renewed, extended or modified in this Commonwealth by any health
4 care insurer shall provide that the health insurance benefits
5 applicable under the policy include coverage for the cost of
6 nutritional supplements (formulas) and low-protein modified food
7 products as medically necessary for the therapeutic treatment of
8 phenylketonuria, branched-chain ketonuria, galactosemia and
9 homocystinuria as administered under the direction of a
10 physician. Coverage for low-protein modified food products for
11 the treatment of phenylketonuria, branched-chain ketonuria,
12 galactosemia and homocystinuria for any calendar year or for any
13 continuous period of 12 months shall not exceed $2,500 for an
14 insured individual subject to adjustment as provided in
15 subsection (b).
16 (b) Adjustment of cap.--
17 (1) The Insurance Department, at least once every three
18 years, shall adjust the $2,500 cap or limit relative set
19 forth in subsection (a) to changes in the components of the
20 Consumer Price Index (Urban) to measure seasonally adjusted
21 changes in low protein modified food product costs and shall
22 make such adjustments to the cap or limit as shall be
23 necessary to maintain the same rate of change in the cap or
24 limit as has occurred in the Consumer Price Index (Urban).
25 Such adjustments may be rounded off to the nearest $50
26 figure.
27 (2) The Insurance Department shall publish the
28 adjustment as a notice in the Pennsylvania Bulletin.
29 Section 6. Cost-sharing provisions.
30 (a) Applicability.--Benefits for nutritional supplements
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1 (formulas) and low-protein modified food products as medically
2 necessary for the therapeutic treatment of phenylketonuria,
3 branched-chain ketonuria, galactosemia and homocystinuria as
4 administered under the direction of a physician shall be subject
5 to copayment and coinsurance provisions of a health insurance
6 policy to the extent that other medical services covered by the
7 policy are subject to those provisions.
8 (b) Exemption.--Benefits for nutritional supplements
9 (formulas) and low-protein modified food products as medically
10 necessary for the therapeutic treatment of phenylketonuria,
11 branched-chain ketonuria, galactosemia and homocystinuria as
12 administered under the direction of a physician shall be exempt
13 from deductible provisions in a health insurance policy. This
14 exemption must be explicitly provided for in the policy.
15 Section 7. Exemption.
16 Notwithstanding sections 4 and 5, this act shall not be
17 construed to require a health insurance policy to include
18 coverage for nutritional supplements (formulas) and low-protein
19 modified food products as medically necessary for the
20 therapeutic treatment of phenylketonuria, branched-chain
21 ketonuria, galactosemia and homocystinuria as administered under
22 the direction of a physician for an individual who is a resident
23 of this Commonwealth if all of the following apply:
24 (1) The individual is employed outside this
25 Commonwealth.
26 (2) The individual's employer maintains a health
27 insurance policy for the individual as an employment benefit.
28 Section 2. This act shall take effect in 180 days.
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