Maryland House Bill 509

This bill was adopted by the Maryland State Legislature in 1995. To date, it is the best and most inclusive to be passed requiring insurance coverage of low protein foods and medical foods (formulas) for treatment of inherited metabolic diseases. There is no age limit, no dollar limit and all metabolic diseases, not just PKU, are included. The wording is very specific and can be used by other states as an excellent model.

 

HOUSE BILL 509

By: Delegates Redmer, Donoghue, Ports, Rosenberg, and Klausmeier
Introduced and read first time: February 3, 1995
Assigned to: Economic Matters
Committee Report: Favorable with amendments
House action: Adopted
Read second time: February 28, 1995
CHAPTER ____

AN ACT concerning: Health Insurance--Foods and Food Products for Inherited Metabolic Diseases.

FOR the purpose of requiring certain health insurance policies, nonprofit health service plans, and health maintenance organizations to include coverage for certain foods and food products for the treatment of certain inherited metabolic diseases under certain circumstances defining certain terms and generally relating to health Insurance coverage for certain foods and food products for certain Inherited metabolic diseases under certain circumstances.

BY adding to:
Article 48A - Insurance Code
Section 354PP, 47OFF, and 477PP
Annotated Code of Maryland
(1994 Replacement Volume and 1994 Supplement)

BY adding to:
Article - Health - General
Scction 19-705.5
Annotated Code of Maryland
(1990 Replacement Volume and 1994, Supplement)

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY 0F MARYLAND, That the Laws of Maryland read as follows:

HOUSE BILL 509
Article 48A - Insurance Code

(A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS INDICATED.

(2) (I) "INHERITED METABOLIC DISEASE" MEANS A DISEASE CAUSED BY AN INHERITED ABNORMALITY OF BODY CHEMISTRY.

(II) "INHERITED METABOLIC DISEASE" INCLUDES A DISEASE FOR WHICH THE STATE SCREENS NEWBORN BABIES,

(3) (I) "LOW PROTEIN MODIFIED FOOD PRODUCT" MEANS A FOOD PRODUCT THAT IS:

1. SPECIALLY FORMULATED TO HAVE LESS THAN 1 GRAM OF PROTEIN PER SERVING: AND

2. INTENDED TO BE USED UNDER THE DIRECTION OF A PHYSICIAN FOR THE DIETARY TREATMENT OF AN INHERITED METAB0LIC DISEASE.

(II) "LOW PROTEIN MODIFIED FOOD PRODUCT" DOES NOT INCLUDE A NATURAL FOOD THAT IS NATURALLY LOW IN PROTEIN.

(4) "MEDICAL FOOD" MEANS A FOOD THAT IS:

(I) INTENDED FOR THE DIETARY TREATMENT OF A DISEASE OR CONDITION FOR WHICH NUTRITIONAL REQUIREMENTS ARE ESTABLISHED BY MEDICAL EVALUATION:

AND

(II) FORMULATED TO BE CONSUMED OR ADMINISTERED ENTERALLY UNDER THE DIRECTION OF A PHYSICIAN.

(B) THE PROVISIONS OF THIS SECTION APPLY TO A NONPROFIT HEALTH SERVICE PLAN THAT:

(1) IS WRITTEN ON AN EXPENSE INCURRED BASIS;

(2) PROVIDES COVERAGE FOR A FAMILY MEMBER OF THE INSURED;

AND

(3) IS DELIVERED OR ISSUED FOR DELIVERY IN THE STATE.

(C) A NONPROFIT HEALTH SERVICE PLAN SHALL INCLUDE UNDER THE FAMILY MEMBER COVERAGE, COVERAGE FOR MEDICAL FOODS AND LOW PROTEIN MODIFIED FOOD PRODUCTS FOR THE TREATMENT OF INHERITED METABOLIC DISEASES IF THE MEDICAL FOODS OR LOW PROTEIN MODIFIED FOOD PRODUCTS

(1) PRESCRIBED AS MEDICALLY NECESSARY FOR THE THERAPEUTIC TREATMENT OF INHERITED METABOLIC DISEASES.

AND

(2) ADMINISTERED UNDER THE DIRECTION OF A PHYSICIAN.

(A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS INDICATED.

(2) (I) "INHERITED METABOLIC DISEASE" MEANS A DISEASE CAUSED BY AN INHERITED ABNORMALITY OF BODY CHEMISTRY.

(II) "INHERITED METABOLIC DISEASE" INCLUDES A DISEASE FOR WHICH THE STATE SCREENS NEWBORN BABIES .

(3) (I) "LOW PROTEIN MODIFIED FOOD PRODUCT" MEANS A FOOD PRODUCT THAT IS:

1. SPECIALLY FORMULATED TO HAVE LESS THAN I GRAM OF PROTEIN PER SERVING, AND

2. INTENDED TO BE USED UNDER THE DIRECTION OF A PHYSICIAN FOR DIETARY TREATMENT OF AN INHERITED METABOLIC DISEASE,

(II) "LOW PROTEIN MODIFIED FOOD PRODUCT" DOES NOT INCLUDE A NATURAL FOOD THAT IS NATURALLY LOW IN PROTEIN,

(4) "MEDICAL FOOD" MEANS THAT A FOOD IS:

(I) INTENDED FOR THE DIETARY TREATMENT OF A DISEASE OR CONDITION FOR WHICH NUTRITIONAL REQUIREMENTS ARE ESTABLISHED BY MEDICAL EVALUATION:

AND

(II) FORMULATED TO BE CONSUMED OR ADMINISTERED ENTERALLY UNDER THE DIRECTION OF A PHYSICIAN.

(B) THE PROVISIONS OF THIS SECTION APPLY TO A HOSPITAL OR MAJOR MEDICAL INSURANCE POLICY THAT:

(1) IS WRITTEN ON AN EXPENSE INCURRED BASIS;

(2) PROVIDES COVERAGE FOR A FAMILY MEMBER OF THE INSURED;

AND

(3) IS DELIVERED OR ISSUED FOR DELIVERY IN THE STATE.

(C) A HOSPITAL OR MAJOR MEDICAL INSURANCE POLICY SHALL

INCLUDE UNDER THE FAMILY MEMBER COVERAGE, COVERAGE FOR MEDICAL FOODS AND LOW PROTEIN MODIFIED FOOD PRODUCTS FOR THE TREATMENT OF INHERITED METABOLIC DISEASES IF THE MEDICAL FOODS OR LOW PROTEIN MODIFIED FOOD PRODUCTS ARE:

(1) PRESCRIBED AS MEDICALLY NECESSARY FOR THE THERAPEUTIC TREATMENT OF INHERITED METABOLIC DISEASES;

AND

(2) ADMINISTERED UNDER THE DIRECTION OF A PHYSICIAN.

(A) (I) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS INDICATED.

(2) (I) "INHERITED METABOLIC DISEASE" MEANS A DISEASE CAUSED BY AN INHERITED ABNORMALITY OF BODY CHEMISTRY.

(II) INHERITED METABOLIC DISEASE" INCLUDES A DISEASE FOR WHICH THE STATE SCREENS NEWBORN BABIES.

(3) (1) "LOW PROTEIN MODIFIED FOOD PRODUCT" MEANS A FOOD PRODUCT THAT IS:

1. SPECIALLY FORMULATED TO HAVE LESS THAN I GRAM OF PROTEIN PER SERVING; AND

2. INTENDED TO BE USED UNDER THE DIRECTION OF A PHYSICIAN FOR THE DIETARY TREATMENT OF AN INHERITED METABOLIC DISEASE

(II) "LOW PROTEIN MODIFIED FOOD PRODUCT" DOES NOT INCLUDE A NATURAL FOOD THAT IS NATURALLY LOW IN PROTEIN.

(4) "MEDICAL FOOD" MEANS A FOOD THAT IS:

(I) INTENDED FOR THE DIETARY TREATMENT OF A DISEASE OR CONDITION FOR WHICH NUTRITIONAL REQUIREMENTS ARE ESTABLISHED BY MEDICAL EVALUATION; AND

(11) FORMULATED TO BE CONSUMED OR ADMINISTERED ENTERALLY UNDER THE DIRECTION OF A PHYSICIAN.

(B) THE PROVISIONS OF THIS SECTION APPLY TO A GROUP OR BLANKET HEALTH INSURANCE POLICY THAT;

(1) IS WRITTEN ON AN EXPENSE INCURRED BASIS;

(2) PROVIDES COVERAGE FOR A FAMILY MEMBER OF THE INSURED AND

(3) IS DELIVERED OR ISSUED FOR DELIVERY IN THE STATE.

(C) A GROUP OR BLANKET HEALTH INSURANCE POLICY SHALL

INCLUDE UNDER THE FAMILY MEMBER COVERAGE, COVERAGE FOR MEDICAL. FOODS AND LOW PROTEIN MODIFIED FOOD PRODUCTS FOR THE TREATMENT OF INHERITED METABOLIC DISEASES IF THE MEDICAL OR LOW PROTEIN MODIFIED FOOD PRODUCTS ARE:

(1) PRESCRIBED AS MEDICALLY NECESSARY FOR THE THERAPEUTIC TREATMENT OF INHERITED METABOLIC DISEASES; AND

(2) ADMINISTERED UNDER THE DIRECTION OF A PHYSICIAN.

Article - Health - General

(A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS INDICATED,

(2) (I) "INHERITED METABOLIC DISEASE" MEANS A DISEASE CAUSED BY AN INHERITED ABNORMALITY OF BODY CHEMISTRY.

(II) "INHERITED METABOLIC DISEASE" INCLUDES A DISEASE FOR WHICH THE STATE SCREENS NEWBORN BABIES.

(3) (I) "LOW PROTEIN MODIFIED FOOD PRODUCT" MEANS A FOOD PRODUCT THAT IS:

1. SPECIALLY FORMULATED TO HAVE LESS THAN I GRAM OF PROTEIN PER SERVING; AND

2. INTENDED TO BE USED UNDER THE DIRECTION OF A PHYSICIAN FOR THE DIETARY TREATMENT OF AN INHERITED METABOLIC DISEASE.

(II) "LOW PROTEIN MODIFIED FOOD PRODUCT" DOES NOT INCLUDE A NATURAL FOOD THAT IS NATURALLY LOW IN PROTEIN.

(4) "MEDICAL FOOD" MEANS A FOOD THAT IS:

(I) INTENDED FOR THE DIETARY TREATMENT OF A DISEASE OR CONDITION FOR WHICH NUTRITIONAL REQUIREMENTS ARE ESTABLISHED BY MEDICAL EVALUATION: AND

(II) FORMULATED TO BE CONSUMED OR ADMINISTERED ENTERALLY UNDER THE DIRECTION OF A PHYSICIAN.

(B) A HEALTH MAINTENANCE ORGANIZATION SHALL INCLUDE AS PART OF ITS BENEFIT PACKAGE OF HEALTH CARE SERVICES TO BE PROVIDED TO MEMBERS AND SUBSCRIBERS COVERAGE FOR MEDICAL FOODS AND LOW PROTEIN MODIFIED FOOD PRODUCTS FOR THE TREATMENT OF INHERITED METABOLIC DISEASES IF THE MEDICAL FOODS AND LOW PROTEIN MODIFIED FOOD PRODUCTS ARE:

(1) PRESCRIBED AS MEDICALLY NECESSARY FOR THE THERAPEUTIC TREATMENT OF INHERITED METABOLIC DISEASES: AND

(2) ADMINISTERED UNDER THE DIRECTION OF A PHYSICIAN.

 

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