Bill Text: CA AB620 | 2023-2024 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Health care coverage for metabolic disorders.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Vetoed) 2024-02-12 - Consideration of Governor's veto stricken from file. [AB620 Detail]
Download: California-2023-AB620-Amended.html
Bill Title: Health care coverage for metabolic disorders.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Vetoed) 2024-02-12 - Consideration of Governor's veto stricken from file. [AB620 Detail]
Download: California-2023-AB620-Amended.html
|
Amended
IN
Assembly
April 27, 2023 |
CALIFORNIA LEGISLATURE—
2023–2024 REGULAR SESSION
Assembly Bill
No. 620
| Introduced by Assembly Member Connolly |
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, as amended, 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 January 1, 2024, to provide coverage for the testing and treatment of other chronic digestive diseases and inherited metabolic disorders. disorders, as specified. 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.
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YESBill Text
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) On and after January 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 the testing and treatment of phenylketonuria (PKU) or other chronic digestive diseases and inherited metabolic disorders under the terms and conditions of the plan contract.(b) (1) Coverage for treatment of PKU or other digestive and inherited metabolic disorders 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 or other digestive and inherited metabolic disorders 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 or other digestive and inherited metabolic disorders.
PKU.
(2) Coverage for treatment of chronic digestive diseases, including, but not limited to, Crohn’s disease, and inherited metabolic disorders, except as otherwise provided 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.
(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) For purposes of this section, the following definitions shall apply:
(1) “Formula” means an enteral product or enteral products 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 or other digestive and inherited metabolic disorders
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 or other digestive and inherited metabolic disorders. 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) On and after January 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 the testing and treatment of phenylketonuria (PKU) or other chronic digestive diseases and inherited metabolic disorders under the terms and conditions of the policy.(b) (1) Coverage for treatment of PKU or other digestive and inherited metabolic disorders
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 or other digestive 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 PKU or other digestive and inherited metabolic disorders. PKU.
(2) Coverage for treatment of chronic digestive diseases, including, but not limited to, Crohn’s disease, and inherited metabolic disorders, except as otherwise provided 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.
(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 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 or other digestive and inherited metabolic disorders 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 or other digestive and inherited metabolic disorders. 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 shall 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, 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, accident-only, specified disease, or hospital indemnity insurance.
