THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY TRUITT, BOBACK, DAVIS, GEORGE, MULLERY, MURT, SAYLOR AND YOUNGBLOOD, OCTOBER 1, 2012

REFERRED TO COMMITTEE ON INSURANCE, OCTOBER 1, 2012  

AN ACT

Requiring prescription drug benefits and health care policies to

provide coverage and reimbursement for amino acid-based

elemental formulas for the treatment of a disease or

disorder.

The General Assembly finds that:

(1)  Children in this Commonwealth are born every year

with gastrointestinal disorders such as Gastrointestinal

Reflux Disease (GERD), multiple severe food protein

allergies, Eosinophilic Esophagitis (EE) and others, which

either prevent proper digestion or result in negative

reaction to certain natural mile or soy products, formulas

and multiple foods.

(2)  These above-listed conditions and others create a

situation where a natural sustained existence is virtually

impossible and threaten a child's ability to thrive.

(3)  As many of these children are unable to process

essential specific naturally occurring nutrients (e.g. whole

milk proteins), parents at the advice and direction of a

licensed health care professional must seek external or oral

elemental formulas, such as amino acid modified formulas and

other specialized formulas, to provide proper and medically

necessary nutrition.

(4)  The amino acid-based elemental formulas and food

products are widely available but expensive in nature due, in

part, to complex scientific manufacturing processes, cost of

raw materials and product quality assurance required for

these at-risk individuals.

(5)  Health insurance policies currently only cover the

cost of specialized amino acid-based elemental formulas when

administered by tube feeding for the most at-risk

individuals, even though tube feeding is not always the least

medically invasive or most cost-effective option available.

(6)  Proper infant and child nutrition significantly

reduces digestion problems and resolves the severe negative

reaction to food protein allergens and other developmental

and physical conditions as well as the need for future, more

expensive medical treatments.

(7)  Medicaid covers the cost of the formulas and food

products.

(8)  The Commonwealth is committed to give each and every

child, regardless of consequence, proper nutrition and high

quality of life.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1.  Coverage and reimbursement for amino-based elemental

formulas.

A hospital, medical service corporation, health insurance

corporation, health maintenance organization and nonprofit group

that provides a prescription drug benefit or reimbursement for

health care costs under a health care policy delivered, issued

for delivery or renewed in this State on or after the effective

date of this section shall provide coverage and reimbursement

for amino acid-based elemental formulas, regardless of delivery

method, for the diagnosis and treatment of Immunoglobulin E and

Non-immunoglobulin E mediated allergies to multiple food

proteins, food protein induced enterocolitis syndrome,

eosinophilic disorders and impaired absorption of nutrients

caused by disorders affecting the absorptive surface, functional

length and motility of the gastrointestinal tract, when the

ordering physician has issued a written order stating that the

amino acid-based elemental formula is medically necessary for

the treatment of a disease or disorder.

Section 2.  Effective date.

This act shall take effect in 60 days.