PRINTER'S NO. 2097
No. 1701 Session of 2001
INTRODUCED BY MICOZZIE, DeLUCA, SATHER, BARRAR, BELARDI,
BENNINGHOFF, CAPPELLI, CLARK, CURRY, DALEY, FEESE, FRANKEL,
GEORGE, HARHAI, HENNESSEY, HORSEY, JAMES, JOSEPHS, KENNEY,
LAUGHLIN, McILHATTAN, S. MILLER, MUNDY, ROHRER, RUBLEY,
SHANER, B. SMITH, SOLOBAY, STERN, E. Z. TAYLOR, J. TAYLOR,
THOMAS, TIGUE, TRELLO, WALKO, WILT AND YOUNGBLOOD,
JUNE 5, 2001
REFERRED TO COMMITTEE ON INSURANCE, JUNE 5, 2001
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
1 ability to process or metabolize amino acids, and, if left
2 untreated or without proper therapeutic management, these
3 disorders cause severe mental retardation and chronic
4 physical disabilities.
5 (3) The only form of treatment is by restricting food
6 intake in order to remove the problem amino acids, which are
7 necessary in the diet, and then replenishing them in
8 carefully controlled measured amounts of a nutritional food
9 substitute.
10 (4) In an attempt to encourage the development of new
11 products, increase availability and reduce cost, formulas
12 were removed from the Federal prescription list and
13 reclassified as medical foods. An unfortunate side effect has
14 been the reluctance of many insurance companies to cover the
15 cost of these formulas. In instances where coverage is
16 provided, it is random and subject to inconsistent
17 interpretation.
18 (5) The intent of this legislation is not to require
19 insurance coverage for [normal food products] natural food
20 products that are naturally low in protein which are used in
21 dietary management of these disorders, but to provide for
22 such coverage of formulas that are equivalent to a
23 prescription drug and low protein modified food products
24 medically necessary for the therapeutic treatment of such
25 rare hereditary genetic metabolic disorders and administered
26 under the direction of a physician.
27 (6) In recognition by the General Assembly that such
28 formulas and low protein modified food products are medically
29 necessary and critical to the well-being of individuals
30 afflicted with rare hereditary genetic metabolic disorders,
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1 it shall be required that health insurance policies issued in
2 this Commonwealth shall include such coverage.
3 Section 3. Definitions.
4 The following words and phrases when used in this act shall
5 have the meanings given to them in this section unless the
6 context clearly indicates otherwise:
7 "Health insurance policy." Except for specified disease and
8 accident-only policies, the term shall mean any group health
9 insurance policy, contract or plan or any individual policy,
10 contract or plan [with coverage for prescription drugs] which
11 provides medical coverage on an expense-incurred, service or
12 prepaid basis. The term includes the following:
13 (1) A health insurance policy or contract issued by a
14 nonprofit corporation subject to 40 Pa.C.S. Chs. 61 (relating
15 to hospital plan corporations) and 63 (relating to
16 professional health services plan corporations) and the act
17 of December 14, 1992 (P.L.835, No.134), known as the
18 Fraternal Benefit Societies Code.
19 (2) A health service plan operating under the act of
20 December 29, 1972 (P.L.1701, No.364), known as the Health
21 Maintenance Organization Act.
22 "Low protein modified food product." A food product that is
23 specially formulated to have less than one gram of protein per
24 serving, and intended to be administered by and used under the
25 direction of a physician for the therapeutic and dietary
26 treatment of phenylketonuria, branched-chain ketonuria,
27 galactosemia and homocystinuria. The term does not include a
28 natural food that is naturally low in protein.
29 Section 4. Medical foods insurance coverage.
30 (a) General rule.--Except as provided in section 7, any
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1 health insurance policy which is delivered, issued for delivery,
2 renewed, extended or modified in this Commonwealth by any health
3 care insurer shall provide that the health insurance benefits
4 applicable under the policy include coverage for the cost of
5 nutritional supplements (formulas) and low protein modified food
6 products as medically necessary for the therapeutic treatment of
7 phenylketonuria, branched-chain ketonuria, galactosemia and
8 homocystinuria as administered under the direction of a
9 physician. Coverage for low protein modified food products for
10 the treatment of phenylketonuria, branched-chain ketonuria,
11 galactosemia and homocystinuria for any calendar year or for any
12 continuous period of 12 months shall not exceed $2,500 for an
13 insured individual subject to adjustment as provided in
14 subsection (b).
15 (b) Adjustment of cap.--
16 (1) The Insurance Department, at least once every three
17 years, shall adjust the $2,500 cap or limit relative set
18 forth in subsection (a) to changes in the components of the
19 Consumer Price Index (Urban) to measure seasonally adjusted
20 changes in low protein modified food product costs and shall
21 make such adjustments to the cap or limit as shall be
22 necessary to maintain the same rate of change in the cap or
23 limit as has occurred in the Consumer Price Index (Urban).
24 Such adjustments may be rounded off to the nearest $50
25 figure.
26 (2) The Insurance Department shall publish the
27 adjustment as a notice in the Pennsylvania Bulletin.
28 Section 6. Cost-sharing provisions.
29 (a) Applicability.--Benefits for nutritional supplements
30 (formulas) and low protein modified food products as medically
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1 necessary for the therapeutic treatment of phenylketonuria,
2 branched-chain ketonuria, galactosemia and homocystinuria as
3 administered under the direction of a physician shall be subject
4 to copayment and coinsurance provisions of a health insurance
5 policy to the extent that other medical services covered by the
6 policy are subject to those provisions.
7 (b) Exemption.--Benefits for nutritional supplements
8 (formulas) and low protein modified food products as medically
9 necessary for the therapeutic treatment of phenylketonuria,
10 branched-chain ketonuria, galactosemia and homocystinuria as
11 administered under the direction of a physician shall be exempt
12 from deductible provisions in a health insurance policy. This
13 exemption must be explicitly provided for in the policy.
14 Section 7. Exemption.
15 Notwithstanding sections 4 and 5, this act shall not be
16 construed to require a health insurance policy to include
17 coverage for nutritional supplements (formulas) and low protein
18 modified food products as medically necessary for the
19 therapeutic treatment of phenylketonuria, branched-chain
20 ketonuria, galactosemia and homocystinuria as administered under
21 the direction of a physician for an individual who is a resident
22 of this Commonwealth if all of the following apply:
23 (1) The individual is employed outside this
24 Commonwealth.
25 (2) The individual's employer maintains a health
26 insurance policy for the individual as an employment benefit.
27 Section 2. This act shall take effect in 180 days.
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