BILL NUMBER: SB 148	ENROLLED
	BILL TEXT

	PASSED THE SENATE   SEPTEMBER 10, 1999
	PASSED THE ASSEMBLY   SEPTEMBER 9, 1999
	AMENDED IN ASSEMBLY   JULY 13, 1999
	AMENDED IN ASSEMBLY   JUNE 29, 1999
	AMENDED IN ASSEMBLY   JUNE 9, 1999
	AMENDED IN SENATE   APRIL 5, 1999
	AMENDED IN SENATE   MARCH 15, 1999
	AMENDED IN SENATE   MARCH 4, 1999

INTRODUCED BY   Senator Alpert
   (Coauthor:  Senator Bowen)

                        JANUARY 6, 1999

   An act to add Section 1374.56 to the Health and Safety Code, and
to add Section 10123.89 to the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   SB 148, Alpert.  Health care coverage:  phenylketonuria (PKU).
   Existing law provides for the licensure and regulation of health
care service plans administered by the Commissioner of Corporations.
Willful violation of those provisions is a crime.  Existing law also
provides for the regulation of disability insurance by the Insurance
Commissioner.
   This bill would require, on and after July 1, 2000, every health
care service plan contract, except a specialized health care service
plan contract, and specified policies of disability insurance,
issued, amended, delivered, or renewed in this state that provide
coverage for hospital, medical, or surgical expenses, to provide
coverage for the testing and treatment of phenylketonuria (PKU) under
the terms and conditions of the plan or policy, as the case may be,
as provided under the bill.
   Since a violation of the provisions regulating health care service
plans would be a crime, this bill would impose a state-mandated
local program by expanding the scope of a crime.
  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.


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


  SECTION 1.  Section 1374.56 is added to the Health and Safety Code,
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 managed by a health care
professional in consultation with a physician 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 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 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. 2.  Section 10123.89 is added to the Insurance Code,
immediately following Section 10123.87, 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 managed by a health care
professional in consultation with a physician 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 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 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. 3.  No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB 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 XIIIB of the California Constitution.