Today's Law As Amended


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AB-1926 Health care coverage: regional enteritis.(2023-2024)



As Amends the Law Today


SECTION 1.

 Section 1374.565 is added to the Health and Safety Code, to read:

1374.565.
 (a) (1) On and after July 1, 2025, 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 dietary enteral formulas, as defined in subdivision (c), for the treatment of regional enteritis.
(2) Coverage for the treatment of the chronic digestive diseases described in paragraph (1) shall include dietary enteral formulas prescribed by a licensed physician and managed by a health care professional in consultation with a physician who specializes in the treatment of chronic digestive diseases and inherited metabolic disorders and who participates in or is authorized by the health plan, provided that the dietary enteral formula 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 regional enteritis.
(b) This section does not apply to Medi-Cal managed care plans contracting with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, to the extent that the services described in this section are excluded from coverage under the contract between the Medi-Cal managed care plan and the State Department of Health Care Services.
(c) For purposes of this section, “dietary enteral formula” means an enteral formula or enteral formulas that may be taken orally 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 regional enteritis.

SEC. 2.

 Section 10123.895 is added to the Insurance Code, to read:

10123.895.
 (a) (1) On and after July 1, 2025, every policy of disability insurance, except a specialized disability insurance policy that provides coverage only for dental or vision benefits, issued, amended, delivered, or renewed in this state that provides coverage for hospital, medical, or surgical expenses shall provide coverage for dietary enteral formulas, as defined in subdivision (c), for the treatment of regional enteritis.
(2) Coverage for the treatment of the chronic digestive diseases described in paragraph (1) shall include dietary enteral formulas prescribed by a licensed physician and managed by a health care professional in consultation with a physician who specializes in the treatment of chronic digestive diseases and inherited metabolic disorders and who participates in or is authorized by the disability insurer, provided that the dietary enteral formula 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 regional enteritis.
(b) This section does not apply to Medi-Cal managed care plans contracting with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, to the extent that the services described in this section are excluded from coverage under the contract between the Medi-Cal managed care plan and the State Department of Health Care Services.
(c) For purposes of this section, “dietary enteral formula” means an enteral formula or enteral formulas that may be taken orally 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 regional enteritis.
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.