BILL NUMBER: AB 30	AMENDED
	BILL TEXT

	AMENDED IN SENATE  AUGUST 4, 2008
	AMENDED IN ASSEMBLY  JANUARY 16, 2008
	AMENDED IN ASSEMBLY  APRIL 10, 2007

INTRODUCED BY   Assembly Member Evans

                        DECEMBER 4, 2006

   An act  to amend Section 1374.56 of, and  to add Section
1374.4 to  ,  the Health and Safety Code,   and to amend
Section 10123.89 of,  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: 
phenylketonuria:  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.  Existing law requires
that this coverage include those formulas and special food products,
as defined, that are part of a diet prescribed by a licensed
physician and managed by a health care professional, as specified.

   This  bill would revise the definition of the term "formula"
for purposes of those provisions and would make related technical
changes. The  bill would  also  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 
 a willful violation of the bill's provisions with respect to
health care service plans  would be a crime,  it
  the bill  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, 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 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   1374.56 of the 
 Health and Safety Code   is amended to read: 
   1374.56.  (a) On and after July 1, 2000, every health care service
plan contract, except a specialized health care service plan
contract, issued, amended, delivered, or renewed in this state that
provides coverage for hospital, medical, or surgical expenses shall
provide coverage for the testing and treatment of phenylketonuria
(PKU) under the terms and conditions of the plan contract.
   (b) Coverage for treatment of phenylketonuria (PKU) 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,
provided that 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 phenylketonuria
(PKU).
   (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 phenylketonuria (PKU).
   (2) "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 phenylketonuria (PKU) 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, phenylketonuria (PKU). 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.
   SEC. 3.    Section 10123.89 of the  
Insurance Code   is amended to read:
   10123.89.  (a) On and after July 1, 2000, every policy of
disability insurance issued, amended, delivered, or renewed in this
state that provides coverage for hospital, medical, or surgical
expenses shall provide coverage for the testing and treatment of
phenylketonuria (PKU) under the terms and conditions of the policy.
   (b) Coverage for treatment of phenylketonuria (PKU) 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,
provided that 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 phenylketonuria
(PKU).
   (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 phenylketonuria (PKU).
   (2) "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 phenylketonuria (PKU) 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, phenylketonuria (PKU). 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) 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. 2.   SEC. 4.   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, 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 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.   SEC. 5.   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.