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

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Date Published: 03/19/2024 09:00 PM
AB1926:v98#DOCUMENT

Amended  IN  Assembly  March 19, 2024

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill
No. 1926

Introduced by Assembly Member Connolly

January 25, 2024

An act to add Section 1374.565 to the Health and Safety Code, and to add Section 10123.895 to the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


AB 1926, as amended, Connolly. Health care coverage: chronic digestive diseases and inherited metabolic disorders. regional enteritis.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, 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 provides for the regulation of disability insurers, including health insurers, by the Department of Insurance. Existing law requires a health care service plan contract and disability insurance policy that provides coverage for hospital, medical, or surgical expenses and is issued, amended, delivered, or renewed on and after July 1, 2000, to provide coverage for the testing and treatment of phenylketonuria, including coverage for the formulas and special food products that are part of a prescribed diet, as specified.
This bill would require a health care service plan contract or disability insurance policy that provides coverage for hospital, medical, or surgical expenses and is issued, amended, delivered, or renewed on and after July 1, 2025, to provide coverage for dietary enteral formulas, as defined, for the treatment of other chronic digestive diseases and inherited metabolic disorders, regional enteritis, as specified. The bill would specify that these provisions do not apply to Medi-Cal managed care plans to the extent that the services are excluded from coverage under the contract between the Medi-Cal managed care plan and the State Department of Health Care Services. Because a violation of the bill’s requirements by a health care service plan would be a crime, 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   Local Program: YES  

The people of the State of California do enact as follows:


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 chronic digestive diseases, including, but not limited to, Crohn’s disease, and inherited metabolic disorders. regional enteritis.
(2) Coverage for the treatment of the chronic digestive diseases described in paragraph (1) shall include those formulas that are part of a diet 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 diet 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 chronic digestive diseases and inherited metabolic disorders. 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, “formula” “dietary enteral formula” means an enteral product or enteral products, including nutritional drinks, for use 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 chronic digestive diseases and inherited metabolic disorders. 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 chronic digestive diseases, including, but not limited to, Crohn’s disease, and inherited metabolic disorders. regional enteritis.
(2) Coverage for the treatment of the chronic digestive diseases described in paragraph (1) shall include those formulas that are part of a diet 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 diet 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 chronic digestive diseases and inherited metabolic disorders. 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, “formula” “dietary enteral formula” means an enteral product or enteral products, including nutritional drinks, for use 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 chronic digestive diseases and inherited metabolic disorders. 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.