REPORT TITLE:
Mandatory Medical Foods Coverage


DESCRIPTION:
Requires health insurance coverage for medical foods and low-
protein modified food products for the treatment of inborn error
of metabolism.  (HB326, HD1, SD1)

 
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HOUSE OF REPRESENTATIVES                H.B. NO.           H.D. 1
TWENTIETH LEGISLATURE, 1999                                S.D. 1
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT

RELATING TO HEALTH INSURANCE.



BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 1      SECTION 1.  Chapter 346, Hawaii Revised Statutes, is amended
 
 2 by adding a new section to be appropriately designated and to
 
 3 read as follows:
 
 4      "346-    Medical foods and low-protein modified food
 
 5 products; treatment of inborn error of metabolism; notice.  (a)
 
 6 Public assistance recipients receiving medical assistance
 
 7 pursuant to this chapter shall be allowed coverage for medical
 
 8 foods and low-protein modified food products for the treatment of
 
 9 an inborn error of metabolism for the recipient or dependents of
 
10 the recipient in this State; provided that the medical food or
 
11 low-protein modified food product is:
 
12      (1)  Prescribed as medically necessary for the therapeutic
 
13           treatment of an inborn error of metabolism;
 
14      (2)  Consumed or administered enterally under the
 
15           supervision of a physician licensed under chapter 453
 
16           or 460; and
 
17      The department shall adopt rules pursuant to chapter 91 to
 
18 effectuate this subsection.
 

 
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 1      (b)  For the purposes of this section:
 
 2      "Inborn error of metabolism" means a disease caused by an
 
 3 inherited abnormality of the body chemistry of a person that is
 
 4 characterized by deficient metabolism, originating from
 
 5 congenital defects or defect arising shortly after birth, of
 
 6 amino acid, organic acid, carbohydrate, or fat.
 
 7      "Low-protein modified food product" means a food product
 
 8 that:
 
 9      (1)  Is specially formulated to have less than one gram of
 
10           protein per serving;
 
11      (2)  Is prescribed or ordered by a physician as medically
 
12           necessary for the dietary treatment of an inborn error
 
13           of metabolism; and
 
14      (3)  Does not include a food that is naturally low in
 
15           protein.
 
16      "Medical food" means a food that is formulated to be
 
17 consumed or administered enterally under the supervision of a
 
18 physician and that is intended for the specific dietary
 
19 management of a disease or condition for which distinctive
 
20 nutritional requirements, based on recognized scientific
 
21 principles, are established by medical evaluation.
 
22      (c)  All health maintenance organizations and prepaid health
 
23 plans with which the department executes risk contracts for the
 

 
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 1 provision of medical care to eligible public assistance
 
 2 recipients shall provide notice to its members regarding the
 
 3 coverage required by this section.  The notice shall be in
 
 4 writing and prominently placed in any literature or
 
 5 correspondence sent to members and shall be transmitted to
 
 6 members within calendar year 2000 when annual information is made
 
 7 available to members, or in any other mailing to members, but in
 
 8 no case later than December 31, 2000."
 
 9      SECTION 2.  Chapter 431, Hawaii Revised Statutes, is amended
 
10 by adding a new section to article 10A to be appropriately
 
11 designated and to read as follows:
 
12      "431:10A-     Medical foods and low-protein modified food
 
13 products; treatment of inborn error of metabolism; notice.  (a)
 
14 Each policy of accident and sickness insurance, other than life
 
15 insurance, disability income insurance, and long-term care
 
16 insurance, issued or renewed in this State, each employer group
 
17 health policy, contract, plan, or agreement issued or renewed in
 
18 this State, all health insurance policies issued or renewed in
 
19 this State, all policies providing family coverages as defined in
 
20 section 431:10A-103, and all policies providing reciprocal
 
21 beneficiary family coverage as defined in section 431:10A-601,
 
22 shall contain a provision for coverage for medical foods and low-
 
23 protein modified food products for the treatment of an inborn
 
24 error of metabolism for its policyholders or dependents of the
 

 
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 1 policyholder in this State; provided that the medical food or low
 
 2 protein modified food product is:
 
 3      (1)  Prescribed as medically necessary for the therapeutic
 
 4           treatment of an inborn error of metabolism;
 
 5      (2)  Consumed or administered enterally under the
 
 6           supervision of a physician licensed under chapter 453
 
 7           or 460; and
 
 8 Coverage shall be for at least eighty per cent of the cost of the
 
 9 medical food or low-protein modified food product prescribed and
 
10 administered pursuant to this subsection.
 
11      (b)  For the purposes of this section:
 
12      "Inborn error of metabolism" means a disease caused by an
 
13 inherited abnormality of the body chemistry of a person that is
 
14 characterized by deficient metabolism, originating from
 
15 congenital defects or defect arising shortly after birth, of
 
16 amino acid, organic acid, carbohydrate, or fat.
 
17      "Low-protein modified food product" means a food product
 
18 that:
 
19      (1)  Is specially formulated to have less than one gram of
 
20           protein per serving;
 
21      (2)  Is prescribed or ordered by a physician as medically
 
22           necessary for the dietary treatment of an inborn error
 

 
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 1           of metabolism; and
 
 2      (3)  Does not include a food that is naturally low in
 
 3           protein.
 
 4      "Medical food" means a food that is formulated to be
 
 5 consumed or administered enterally under the supervision of a
 
 6 physician and that is intended for the specific dietary
 
 7 management of a disease or condition for which distinctive
 
 8 nutritional requirements, based on recognized scientific
 
 9 principles, are established by medical evaluation.
 
10      (c)  Every insurer shall provide notice to its policyholders
 
11 regarding the coverage required by this section.  The notice
 
12 shall be in writing and prominently placed in any literature or
 
13 correspondence sent to policyholders and shall be transmitted to
 
14 policyholders within calendar year 2000 when annual information
 
15 is made available to policyholders, or in any other mailing to
 
16 policyholders, but in no case later than December 31, 2000."
 
17      SECTION 3.  Chapter 432, Hawaii Revised Statutes, is amended
 
18 by adding a new section to article 1 to be appropriately
 
19 designated and to read as follows:
 
20      "432:1-     Medical foods and low-protein modified food
 
21 products; treatment of inborn error of metabolism; notice.  (a)
 
22 All individual and group hospital and medical service plan
 
23 contracts and medical service corporation contracts under this
 

 
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 1 chapter shall provide coverage for medical foods and low-protein
 
 2 modified food products for the treatment of an inborn error of
 
 3 metabolism for its members or dependents of the member in this
 
 4 State; provided that the medical food or low-protein modified
 
 5 food product is:
 
 6      (1)  Prescribed as medically necessary for the therapeutic
 
 7           treatment of an inborn error of metabolism;
 
 8      (2)  Consumed or administered enterally under the
 
 9           supervision of a physician licensed under chapter 453
 
10           or 460; and
 
11 Coverage shall be for at least eighty per cent of the cost of the
 
12 medical food or low-protein modified food product prescribed and
 
13 administered pursuant to this subsection.
 
14      (b)  For the purposes of this section:
 
15      "Inborn error of metabolism" means a disease caused by an
 
16 inherited abnormality of the body chemistry of a person that is
 
17 characterized by deficient metabolism, originating from
 
18 congenital defects or defect arising shortly after birth, of
 
19 amino acid, organic acid, carbohydrate, or fat.
 
20      "Low-protein modified food product" means a food product
 
21 that:
 
22      (1)  Is specially formulated to have less than one gram of
 
23           protein per serving;
 

 
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 1      (2)  Is prescribed or ordered by a physician as medically
 
 2           necessary for the dietary treatment of an inherited
 
 3           metabolic disease; and
 
 4      (3)  Does not include a food that is naturally low in
 
 5           protein.
 
 6      "Medical food" means a food that is formulated to be
 
 7 consumed or administered enterally under the supervision of a
 
 8 physician and that is intended for the specific dietary
 
 9 management of a disease or condition for which distinctive
 
10 nutritional requirements, based on recognized scientific
 
11 principles, are established by medical evaluation.
 
12      (c)  Every mutual benefit society shall provide notice to
 
13 its members regarding the coverage required by this section.  The
 
14 notice shall be in writing and prominently placed in any
 
15 literature or correspondence sent to members and shall be
 
16 transmitted to members within calendar year 2000 when annual
 
17 information is made available to members, or in any other mailing
 
18 to members, but in no case later than December 31, 2000."
 
19      SECTION 4.  Chapter 432D-23, Hawaii Revised Statutes, is
 
20 amended to read as follows:
 
21      "[[]432D-23[]]  Required provisions and benefits.
 
22 Notwithstanding any provision of law to the contrary, each
 
23 policy, contract, plan, or agreement issued in the State after
 

 
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 1 January 1, 1995, by health maintenance organizations pursuant to
 
 2 this chapter, shall include benefits provided in sections
 
 3 431:10-212, 431:10A-115, 431:10A-115.5, 431:10A-116,
 
 4 431:10A-116.5, [and] 431:10A-116.6, 431:10A-   , and chapter
 
 5 431M."
 
 6      SECTION 5.  Statutory material to be repealed is bracketed.
 
 7 New statutory material is underscored.
 
 8      SECTION 6.  This Act shall take effect upon its approval.
 

 
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