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)

 
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HOUSE OF REPRESENTATIVES                H.B. NO.           H.D. 1
TWENTIETH LEGISLATURE, 1999                                
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  inborn error of metabolism for the recipient or dependents of the
 
  10  recipient in this State; provided that the medical food or low-
 
  11  protein modified food product is:
 
  12       (1)  Prescribed as medically necessary for the therapeutic
 
  13            treatment of 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       (3)  Not a commonly available commercial preparation.
 
  18  Coverage shall be for at least eighty per cent of the cost of the
 
  19  medical food or low-protein modified food product prescribed and
 

 
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   1  administered pursuant to this subsection.
 
   2       The department shall adopt rules pursuant to chapter 91 to
 
   3  effectuate this subsection.
 
   4       (b)  For the purposes of this section:
 
   5       "Inborn error of metabolism" means a disease caused by an
 
   6  inherited abnormality of the body chemistry of a person that is
 
   7  characterized by deficient metabolism, originating from
 
   8  congenital defects or defect arising shortly after birth, of
 
   9  amino acid, organic acid, carbohydrate, or fat.
 
  10       "Low-protein modified food product" means a food product
 
  11  that:
 
  12       (1)  Is specially formulated to have less than one gram of
 
  13            protein per serving;
 
  14       (2)  Is prescribed or ordered by a physician as medically
 
  15            necessary for the dietary treatment of an inborn error
 
  16            of metabolism; and
 
  17       (3)  Does not include a food that is naturally low in
 
  18            protein.
 
  19       "Medical food" means a food that is formulated to be
 
  20  consumed or administered enterally under the supervision of a
 
  21  physician and that is intended for the specific dietary
 
  22  management of a disease or condition for which distinctive
 
  23  nutritional requirements, based on recognized scientific
 

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

 
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                                        H.B. NO.           H.D. 1
                                                           
                                                           

 
   1  beneficiary family coverage as defined in section 431:10A-601,
 
   2  shall contain a provision for coverage for medical foods and low-
 
   3  protein modified food products for the treatment of inborn error
 
   4  of metabolism for its policyholders or dependents of the
 
   5  policyholder in this State; provided that the medical food or low
 
   6  protein modified food product is:
 
   7       (1)  Prescribed as medically necessary for the therapeutic
 
   8            treatment of inborn error of metabolism;
 
   9       (2)  Consumed or administered enterally under the
 
  10            supervision of a physician licensed under chapter 453
 
  11            or 460; and
 
  12       (3)  Not a commonly available commercial preparation.
 
  13  Coverage shall be for at least eighty per cent of the cost of the
 
  14  medical food or low-protein modified food product prescribed and
 
  15  administered pursuant to this subsection.
 
  16       (b)  For the purposes of this section:
 
  17       "Inborn error of metabolism" means a disease caused by an
 
  18  inherited abnormality of the body chemistry of a person that is
 
  19  characterized by deficient metabolism, originating from
 
  20  congenital defects or defect arising shortly after birth, of
 
  21  amino acid, organic acid, carbohydrate, or fat.
 
  22       "Low-protein modified food product" means a food product
 
  23  that:
 

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

 
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   1       "432:1-     Medical foods and low-protein modified food
 
   2  products; treatment of inborn error of metabolism; notice.  (a)
 
   3  All individual and group hospital and medical service plan
 
   4  contracts and medical service corporation contracts under this
 
   5  chapter shall provide coverage for medical foods and low-protein
 
   6  modified food products for the treatment of inborn error of
 
   7  metabolism for its members or dependents of the member in this
 
   8  State; provided that the medical food or low-protein modified
 
   9  food product is:
 
  10       (1)  Prescribed as medically necessary for the therapeutic
 
  11            treatment of inborn error of metabolism;
 
  12       (2)  Consumed or administered enterally under the
 
  13            supervision of a physician licensed under chapter 453
 
  14            or 460; and
 
  15       (3)  Not a commonly available commercial preparation.
 
  16  Coverage shall be for at least eighty per cent of the cost of the
 
  17  medical food or low-protein modified food product prescribed and
 
  18  administered pursuant to this subsection.
 
  19       (b)  For the purposes of this section:
 
  20       "Inborn error of metabolism" means a disease caused by an
 
  21  inherited abnormality of the body chemistry of a person that is
 
  22  characterized by deficient metabolism, originating from
 
  23  congenital defects or defect arising shortly after birth, of
 

 
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   1  amino acid, organic acid, carbohydrate, or fat.
 
   2       "Low-protein modified food product" means a food product
 
   3  that:
 
   4       (1)  Is specially formulated to have less than one gram of
 
   5            protein per serving;
 
   6       (2)  Is prescribed or ordered by a physician as medically
 
   7            necessary for the dietary treatment of an inherited
 
   8            metabolic disease; and
 
   9       (3)  Does not include a food that is naturally low in
 
  10            protein.
 
  11       "Medical food" means a food that is formulated to be
 
  12  consumed or administered enterally under the supervision of a
 
  13  physician and that is intended for the specific dietary
 
  14  management of a disease or condition for which distinctive
 
  15  nutritional requirements, based on recognized scientific
 
  16  principles, are established by medical evaluation.
 
  17       (c)  Every insurer shall provide notice to its members
 
  18  regarding the coverage required by this section.  The notice
 
  19  shall be in writing and prominently placed in any literature or
 
  20  correspondence sent to members and shall be transmitted to
 
  21  members within calendar year 2000 when annual information is made
 
  22  available to members, or in any other mailing to members, but in
 
  23  no case later than December 31, 2000."
 

 
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   1       SECTION 4.  Chapter 432D-23, Hawaii Revised Statutes, is
 
   2  amended to read as follows:
 
   3       "[[]432D-23[]]  Required provisions and benefits.
 
   4  Notwithstanding any provision of law to the contrary, each
 
   5  policy, contract, plan, or agreement issued in the State after
 
   6  January 1, 1995, by health maintenance organizations pursuant to
 
   7  this chapter, shall include benefits provided in sections
 
   8  431:10-212, 431:10A-115, 431:10A-115.5, 431:10A-116,
 
   9  431:10A-116.5, [and] 431:10A-116.6, 431:10A-   , and chapter
 
  10  431M."
 
  11       SECTION 5.  Statutory material to be repealed is bracketed.
 
  12  New statutory material is underscored.
 
  13       SECTION 6.  This Act shall take effect upon its approval.
 

 
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