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2002 SESSION

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025872876
HOUSE BILL NO. 84 Offered January 9, 2002 Prefiled December 19, 2001 A BILL to amend and reenact з 38.2-4319, as it is currently effective and as it shall become effective, of the Code of Virginia and to amend the Code of Virginia by adding a section numbered 38.2-3418.14, relating to health insurance coverage for polypeptide-based or amino acid-based formulas. ---------- Patron-- Orrock ---------- Referred to Committee on Commerce and Labor ----------

Be it enacted by the General Assembly of Virginia:

1. That з 38.2-4319 of the Code of Virginia, as it is currently effective and as it shall become effective, is amended and reenacted, and that the Code of Virginia is amended by adding a section numbered 38.2-3418.14 as follows:

з 38.2-3418.14. Coverage for polypeptide-based or amino acid-based formulas.

A. Notwithstanding the provisions of з 38.2-3419, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall provide coverage, as provided in this section, for the expense of polypeptide-based or amino acid-based formulas whose protein source has been extensively or completely hydrolyzed.

B. Coverage under this section shall apply only if:

1. The polypeptide-based or amino acid-based formula is prescribed by a licensed physician. A managed care health insurance plan, as defined in Chapter 58 (з 38.2-5800 et seq.) of this title, may require such physician to be a member of the plan's provider network;

2. The physician furnishes supporting documentation to the insurer, corporation, or health maintenance organization that the polypeptide-based or amino acid-based formula is required to treat either a diagnosed inborn error of amino acid or organic acid metabolism or a diagnosed disease or disorder of the gastrointestinal tract that leads to malnutrition or malabsorption due to inflammation, protein sensitivity, or inborn errors of digestion; and

3. The polypeptide-based or amino acid-based formula is the primary source of nutrition as certified by the treating physician by diagnosis.

C. No insurer, corporation, or health maintenance organization shall impose upon any person receiving benefits pursuant to this section any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, nor shall any insurer, corporation, or health maintenance organization impose any policy-year or calendar-year dollar or durational benefit limitations or maximums for benefits provided under this section.

D. The requirements of this section shall apply to all insurance policies, contracts, and plans delivered, issued for delivery, reissued, renewed or extended in this Commonwealth on and after July 1, 2002, or at any time thereafter when any term of the policy, contract or plan is changed or any premium adjustment is made.

E. The provisions of this section shall not apply to short-term travel, accident-only, short-term nonrenewable policies of not more than six months' duration, limited or specified disease policies, or policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.

з 38.2-4319. (Effective until July 1, 2004) Statutory construction and relationship to other laws.

A. No provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, зз 38.2-100, 38.2-200, 38.2-203, 38.2-209 through 38.2-213, 38.2-218 through 38.2-225, 38.2-229, 38.2-232, 38.2-305, 38.2-316, 38.2-322, 38.2-400, 38.2-402 through 38.2-413, 38.2-500 through 38.2-515, 38.2-600 through 38.2-620, Chapter 9 (з 38.2-900 et seq.), зз 38.2-1017 through 38.2-1023, 38.2-1057, Articles 2 (з 38.2-1306 et seq.), 4 (з 38.2-1317 et seq.) and 5 (з 38.2-1322 et seq.) of Chapter 13, Articles 1 (з 38.2-1400 et seq.) and 2 (з 38.2-1412 et seq.) of Chapter 14, зз 38.2-1800 through 38.2-1836, 38.2-3401, 38.2-3405, 38.2-3405.1, 38.2-3407.2 through 38.2-3407.6:1, 38.2-3407.9 through 38.2-3407.16, 38.2-3411.2, 38.2-3411.3, 38.2-3411.4, 38.2-3412.1:01, 38.2-3414.1, 38.2-3418.1 through 38.2-3418.12, 38.2-3418.14, 38.2-3419.1, 38.2-3430.1 through 38.2-3437, 38.2-3500, subdivision 13 of з 38.2-3503, subdivision 8 of з 38.2-3504, зз 38.2-3514.1, 38.2-3514.2, 38.2-3522.1 through 38.2-3523.4, 38.2-3525, 38.2-3542, 38.2-3543.2, Chapter 52 (з 38.2-5200 et seq.), Chapter 55 (з 38.2-5500 et seq.), Chapter 58 (з 38.2-5800 et seq.), and з 38.2-5903 of this title shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (з 38.2-4200 et seq.) of this title except with respect to the activities of its health maintenance organization.

B. Solicitation of enrollees by a licensed health maintenance organization or by its representatives shall not be construed to violate any provisions of law relating to solicitation or advertising by health professionals.

C. A licensed health maintenance organization shall not be deemed to be engaged in the unlawful practice of medicine. All health care providers associated with a health maintenance organization shall be subject to all provisions of law.

D. Notwithstanding the definition of an eligible employee as set forth in з 38.2-3431, a health maintenance organization providing health care plans pursuant to з 38.2-3431 shall not be required to offer coverage to or accept applications from an employee who does not reside within the health maintenance organization's service area.

E. For purposes of applying this section, "insurer" when used in a section cited in subsection A of this section shall be construed to mean and include "health maintenance organizations" unless the section cited clearly applies to health maintenance organizations without such construction.

з 38.2-4319. (Effective July 1, 2004) Statutory construction and relationship to other laws.

A. No provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, зз 38.2-100, 38.2-200, 38.2-203, 38.2-209 through 38.2-213, 38.2-218 through 38.2-225, 38.2-229, 38.2-232, 38.2-305, 38.2-316, 38.2-322, 38.2-400, 38.2-402 through 38.2-413, 38.2-500 through 38.2-515, 38.2-600 through 38.2-620, Chapter 9 (з 38.2-900 et seq.), зз 38.2-1017 through 38.2-1023, 38.2-1057, Articles 2 (з 38.2-1306 et seq.), 4 (з 38.2-1317 et seq.) and 5 (з 38.2-1322 et seq.) of Chapter 13, Articles 1 (з 38.2-1400 et seq.) and 2 (з 38.2-1412 et seq.) of Chapter 14, зз 38.2-1800 through 38.2-1836, 38.2-3401, 38.2-3405, 38.2-3405.1, 38.2-3407.2 through 38.2-3407.6:1, 38.2-3407.9 through 38.2-3407.16, 38.2-3411.2, 38.2-3411.3, 38.2-3411.4, 38.2-3414.1, 38.2-3418.1 through 38.2-3418.12, 38.2-3418.14, 38.2-3419.1, 38.2-3430.1 through 38.2-3437, 38.2-3500, subdivision 13 of з 38.2-3503, subdivision 8 of з 38.2-3504, зз 38.2-3514.1, 38.2-3514.2, 38.2-3522.1 through 38.2-3523.4, 38.2-3525, 38.2-3542, 38.2-3543.2, Chapter 52 (з 38.2-5200 et seq.), Chapter 55 (з 38.2-5500 et seq.), Chapter 58 (з 38.2-5800 et seq.) and з 38.2-5903 of this title shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (з 38.2-4200 et seq.) of this title except with respect to the activities of its health maintenance organization.