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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                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 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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                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 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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                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 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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                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 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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                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 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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                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 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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