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AB-620 Health care coverage for metabolic disorders.(2023-2024)

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Date Published: 09/18/2023 09:00 PM
AB620:v94#DOCUMENT

Enrolled  September 18, 2023
Passed  IN  Senate  September 13, 2023
Passed  IN  Assembly  September 14, 2023
Amended  IN  Senate  September 08, 2023
Amended  IN  Senate  September 01, 2023
Amended  IN  Senate  June 20, 2023
Amended  IN  Assembly  April 27, 2023

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill
No. 620

Introduced by Assembly Member Connolly
(Coauthor: Assembly Member Bonta)

February 09, 2023

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


LEGISLATIVE COUNSEL'S DIGEST


AB 620, Connolly. Health care coverage for metabolic disorders.
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 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, 2024, to provide coverage for formulas, as defined, for the treatment of other chronic digestive diseases and inherited metabolic disorders, 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 1374.56 of the Health and Safety Code is amended to read:

1374.56.
 (a)  (1) 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.
(2)  Coverage for treatment of 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 PKU.
(b) (1) On and after July 1, 2024, 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 formulas, as defined in paragraph (1) of subdivision (e), for the treatment of chronic digestive diseases, including, but not limited to, Crohn’s disease, and inherited metabolic disorders, except as otherwise provided in subdivision (a) under the terms and conditions of the plan contract.
(2) Coverage for the treatment of the chronic digestive diseases described in paragraph (1) shall include those formulas 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 chronic digestive diseases and inherited metabolic disorders and who participates in or is authorized by the health 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 chronic digestive diseases and inherited metabolic disorders. The coverage required by this paragraph shall not include special food products as defined in paragraph (2) of subdivision (e).
(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) This section shall 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.
(e) For purposes of this section, the following definitions shall apply:
(1) “Formula” means an enteral product or enteral products, including nutritional drinks, 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 PKU or other chronic digestive diseases and inherited metabolic disorders.
(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 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, 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 of the Insurance Code is amended to read:

10123.89.
 (a) (1) 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.
(2) Coverage for treatment of 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 PKU.
(b) (1) On and after July 1, 2024, 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 formulas, as defined in paragraph (1) of subdivision (d), for the treatment of chronic digestive diseases, including, but not limited to, Crohn’s disease, and inherited metabolic disorders, except as otherwise provided in subdivision (a) under the terms and conditions of the policy.
(2) Coverage for the treatment of the chronic digestive diseases described in paragraph (1) shall include those formulas 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 chronic digestive diseases and inherited metabolic disorders 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 chronic digestive diseases and inherited metabolic disorders. The coverage required by this paragraph shall not include special food products as defined in paragraph (2) of subdivision (d).
(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, including nutritional drinks, 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 PKU or other chronic digestive diseases and inherited metabolic disorders.
(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 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, 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 does 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. This section does not impose a new benefit mandate on accident-only, specified disease, or hospital indemnity insurance.
(f) This section shall 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.

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.