376.1219. PKU formula and low protein modified food products covered by insurance, when--exceptions.
PKU formula and low protein modified food products covered byinsurance, when--exceptions.
376.1219. 1. Each policy issued by an entity offering individual andgroup health insurance which provides coverage on an expense-incurred basis,individual and group health service or indemnity type contracts issued by anonprofit corporation, individual and group service contracts issued by ahealth maintenance organization, all self-insured group health arrangements tothe extent not preempted by federal law, and all health care plans provided bymanaged health care delivery entities of any type or description, that aredelivered, issued for delivery, continued or renewed in this state on or afterSeptember 1, 1997, shall provide coverage for formula and low protein modifiedfood products recommended by a physician for the treatment of a patient withphenylketonuria or any inherited disease of amino and organic acids who iscovered under the policy, contract, or plan and who is less than six years ofage.
2. For purposes of this section, "low protein modified food products"means foods that are specifically formulated to have less than one gram ofprotein per serving and are intended to be used under the direction of aphysician for the dietary treatment of any inherited metabolic disease. Lowprotein modified food products do not include foods that are naturally low inprotein.
3. The coverage required by this section may be subject to the samedeductible for similar health care services provided by the policy, contract,or plan as well as a reasonable coinsurance or co-payment on the part of theinsured, which shall not be greater than fifty percent of the cost of theformula and food products, and may be subject to an annual benefit maximum ofnot less than five thousand dollars per covered child. Nothing in thissection shall prohibit a carrier from using individual case management or fromcontracting with vendors of the formula and food products.
4. This section shall not apply to a supplemental insurance policy,including a life care contract, accident-only policy, specified diseasepolicy, hospital policy providing a fixed daily benefit only, Medicaresupplement policy, long-term care policy, or any other supplemental policy asdetermined by the director of the department of insurance, financialinstitutions and professional registration.
(L. 1997 H.B. 600 & 388, A.L. 2002 S.B. 1026)