BILL NUMBER: SB 148 CHAPTERED 09/28/99 CHAPTER 541 FILED WITH SECRETARY OF STATE SEPTEMBER 28, 1999 APPROVED BY GOVERNOR SEPTEMBER 27, 1999 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.