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, for cost-
7sharing 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:

13AN ACT

14Providing for certain health insurance policies to cover the

15 cost of formulas necessary for the treatment of

16 phenylketonuria and related disorders and food-related

17 allergic disorders.

18Section 2. Declaration of policy.

19The General Assembly finds and declares as follows:

20(1) Phenylketonuria (PKU), branched-chain ketonuria,

1galactosemia and homocystinuria are aminoacidopathies that
2are rare hereditary genetic metabolic disorders.

3(2) Lacking in these aminoacidopathies is the body's
4ability to process or metabolize amino acids, and, if left
5untreated or without proper therapeutic management, these
6disorders cause severe mental retardation and chronic
7physical disabilities.

8(3) The only form of treatment is by restricting food
9intake in order to remove the problem amino acids, which are
10necessary in the diet, and then replenishing them in
11carefully controlled measured amounts of a nutritional food
12substitute.

13(4) In an attempt to encourage the development of new
14products, increase availability and reduce cost, formulas
15were removed from the Federal prescription list and
16reclassified as medical foods. An unfortunate side effect has
17been the reluctance of many insurance companies to cover the
18cost of these formulas. In instances where coverage is
19provided, it is random and subject to inconsistent
20interpretation.

21(5) The intent of this legislation is not to require
22insurance coverage for normal food products used in dietary
23management of these disorders, but to provide for such
24coverage of formulas that are equivalent to a prescription
25drug medically necessary for the therapeutic treatment and 
26dietary management of such rare hereditary genetic metabolic
27and food-related allergic disorders, and administered under
28the direction of a physician.

29(6) In recognition by the General Assembly that such
30formulas are medically necessary and critical to the well-

1being of individuals afflicted with rare hereditary genetic
2metabolic and food-related allergic disorders, it shall be
3required that health insurance policies issued in this
4Commonwealth shall include such coverage.

5Section 4. Medical foods insurance coverage.

6Except as provided in section 7, any health insurance policy
7which is delivered, issued for delivery, renewed, extended or
8modified in this Commonwealth by any health care insurer shall
9provide that the health insurance benefits applicable under the
10policy include coverage for the cost of nutritional supplements
11(formulas) as medically necessary for the therapeutic treatment
12of phenylketonuria, branched-chain ketonuria, galactosemia
13[and], homocystinuria, IgE and Non-IgE mediated food protein 
14allergies, food protein-induced enterocolitis syndrome, 
15eosinophilic disorders and short-bowel syndrome as administered
16under the direction of a physician.

17Section 6. Cost-sharing provisions.

18(a) Applicability.--Benefits for nutritional supplements
19(formulas) as medically necessary for the therapeutic treatment
20of phenylketonuria, branched-chain ketonuria, galactosemia
21[and], homocystinuria and food-related allergic disorders as
22administered under the direction of a physician shall be subject
23to copayment and coinsurance provisions of a health insurance
24policy to the extent that other medical services covered by the
25policy are subject to those provisions.

26(b) Exemption.--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 exempt from deductible provisions in a health

1insurance policy. This exemption must be explicitly provided for
2in the policy.

3Section 7. Exemption.

4Notwithstanding sections 4 and 5, this act shall not be
5construed to require a health insurance policy to include
6coverage for nutritional supplements (formulas) as medically
7necessary for the therapeutic treatment of phenylketonuria,
8branched-chain ketonuria, galactosemia [and], homocystinuria and 
9food-related allergic disorders as administered under the
10direction of a physician for an individual who is a resident of
11this Commonwealth if all of the following apply:

12(1) The individual is employed outside this
13Commonwealth.

14(2) The individual's employer maintains a health
15insurance policy for the individual as an employment benefit.

16Section 2. This act shall take effect in 180 days.