BILL NUMBER: AB 30	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  JANUARY 16, 2008
	AMENDED IN ASSEMBLY  APRIL 10, 2007

INTRODUCED BY   Assembly Member Evans

                        DECEMBER 4, 2006

   An act to add Section 1374.4 to the Health and Safety Code, and to
add Section 10123.90 to the Insurance Code, relating to health care
coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 30, as amended, Evans. Health care coverage: inborn errors of
metabolism.
   Existing law, the Knox-Keene Health Care Service Plan Act of 1975
(the Knox-Keene Act), provides for the licensure and regulation of
health care service plans by the Department of Managed Health Care
and makes a willful violation of the act a crime. Existing law also
provides for the regulation of health insurers by the Department of
Insurance. Under existing law, a plan and a health insurer are
required to provide coverage, as specified, for the testing and
treatment of phenylketonuria.
   This bill would extend this coverage requirement for health care
service plans and insurers, as specified, to inborn errors of
metabolism, as defined.
   Because the bill would specify an additional requirement under the
Knox-Keene Act, the willful violation of which would be a crime, it
would impose a state-mandated local program.
   The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1374.4 is added to the Health and Safety Code,
to read:
   1374.4.  (a) Every health care service plan contract, except a
specialized health care service plan contract, issued, amended,
delivered, or renewed in this state on and after January 1, 
2008,   2009,  that provides coverage for hospital,
medical, or surgical expenses shall provide coverage for the testing
and treatment of inborn errors of metabolism under the terms and
conditions of the plan contract.
   (b) Coverage for treatment of inborn errors of metabolism shall
include those formulas and special food products that are part of a
diet prescribed by a licensed physician and surgeon and managed by a
health care professional in consultation with a physician and surgeon
who specializes in the treatment of metabolic disease and who
participates in, or is authorized by, the plan, if the diet is deemed
medically necessary to avert the development of serious physical or
mental disabilities or to promote normal development or function as a
consequence of inborn errors of metabolism.
   (c) Coverage pursuant to this section is not required except to
the extent that the cost of the necessary formulas and special food
products exceeds the cost of a normal diet.
   (d) For purposes of this section, the following definitions shall
apply:
   (1) "Formula" means an enteral product or enteral products
 for use at home  that are prescribed by a physician
and surgeon or nurse practitioner, or ordered by a registered
dietician upon referral by a health care provider authorized to
prescribe dietary treatments, as medically necessary for the
treatment of inborn errors of metabolism.
   (2) "Inborn errors of metabolism" means an inheritable disorder of
biochemistry detected through the California newborn screening
program.
   (3) "Special food product" means a food product that is both of
the following:
   (A) Prescribed by a physician and surgeon or nurse practitioner
for the treatment of inborn errors of metabolism and is consistent
with the recommendations and best practices of qualified health
professionals with expertise germane to, and experience in the
treatment and care of, inborn errors of metabolism. It does not
include a food that is naturally low in protein, but may include a
food product that is specially formulated to have less than one gram
of protein per serving.
   (B) Used in place of normal food products, such as grocery store
foods, used by the general population.
   (e) A plan that provides the coverage required by this section
shall be deemed to comply with Section 1374.56.
  SEC. 2.  Section 10123.90 is added to the Insurance Code, to read:
   10123.90.  (a) Every policy of health insurance issued, amended,
delivered, or renewed in this state on and after January 1, 
2008,   2009,  that provides coverage for hospital,
medical, or surgical expenses shall provide coverage for the testing
and treatment of inborn errors of metabolism under the terms and
conditions of the policy.
   (b) Coverage for treatment of inborn errors of metabolism shall
include those formulas and special food products that are part of a
diet prescribed by a licensed physician and surgeon and managed by a
health care professional in consultation with a physician and surgeon
who specializes in the treatment of metabolic disease and who
participates in, or is authorized by, the insurer, if the diet is
deemed medically necessary to avert the development of serious
physical or mental disabilities or to promote normal development or
function as a consequence of inborn errors of metabolism.
   (c) Coverage pursuant to this section is not required except to
the extent that the cost of necessary formulas and special food
products exceeds the cost of a normal diet.
   (d) For purposes of this section, the following definitions shall
apply:
   (1) "Formula" means an enteral product or enteral products
 for use at home  that are prescribed by a physician
and surgeon or nurse practitioner, or ordered by a registered
dietician upon referral by a health care provider authorized to
prescribe dietary treatments, as medically necessary for the
treatment of inborn errors of metabolism.
   (2) "Inborn errors of metabolism" means an inheritable disorder of
biochemistry detected through the California newborn screening
program.
   (3) "Special food product" means a food product that is both of
the following:
   (A) Prescribed by a physician and surgeon or nurse practitioner
for the treatment of inborn errors of metabolism and is consistent
with the recommendations and best practices of qualified health
professionals with expertise germane to, and experience in the
treatment and care of, inborn errors of metabolism. It does not
include a food that is naturally low in protein, but may include a
food product that is specially formulated to have less than one gram
of protein per serving.
   (B) Used in place of normal food products, such as grocery store
foods, used by the general population.
   (e) A health insurer that provides the coverage required by this
section shall be deemed to comply with Section 10123.89.
   (f) This section shall not apply to vision-only, dental-only,
accident-only, specified disease, hospital indemnity, Medicare
supplement, long-term care, or disability income insurance, except
that for accident only, specified disease, or hospital indemnity
coverage, coverage for benefits under this section shall apply to the
extent that the benefits are covered under the general terms and
conditions that apply to all other benefits under the policy or
contract. Nothing in this section shall be construed as imposing a
new benefit mandate on accident only, specified disease, or hospital
indemnity insurance.
  SEC. 3.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.