20-2327. Metabolic disorders; medical foods;
definitions
A. Any health benefits plan that is offered by an accountable health plan and that
contains a prescription drug benefit shall provide coverage of medical foods to treat
inherited metabolic disorders as provided by this section.
B. The metabolic disorders triggering medical foods coverage under this section
shall:
1. Be part of the newborn screening program prescribed in section 36-694.
2. Involve amino acid, carbohydrate or fat metabolism.
3. Have medically standard methods of diagnosis, treatment and monitoring,
including quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA
confirmation in tissues.
4. Require specially processed or treated medical foods that are generally
available only under the supervision and direction of a physician who is licensed
pursuant to title 32, chapter 13 or 17 or a registered nurse practitioner who is licensed
pursuant to title 32, chapter 15, that must be consumed throughout life and without which
the person may suffer serious mental or physical impairment.
C. Medical foods eligible for coverage under this section shall be prescribed or
ordered under the supervision of a physician licensed pursuant to title 32, chapter 13 or
17 or a registered nurse practitioner who is licensed pursuant to title 32, chapter 15 as
medically necessary for the therapeutic treatment of an inherited metabolic disease.
D. An accountable health plan shall cover at least fifty per cent of the cost of
medical foods prescribed to treat inherited metabolic disorders and covered pursuant to
this section. A plan may limit the maximum annual benefit for medical foods under this
section to five thousand dollars that applies to the cost of all prescribed modified low
protein foods and metabolic formula.
E. For the purposes of this section:
1. "Inherited metabolic disorder" means a disease caused by an inherited
abnormality of body chemistry and includes a disease tested under the newborn screening
program prescribed in section 36-694.
2. "Medical foods" means modified low protein foods and metabolic formula.
3. "Metabolic formula" means foods that are all of the following:
(a) Formulated to be consumed or administered enterally under the supervision of a
physician who is licensed pursuant to title 32, chapter 13 or 17 or a registered nurse
practitioner who is licensed pursuant to title 32, chapter 15.
(b) Processed or formulated to be deficient in one or more of the nutrients present
in typical foodstuffs.
(c) Administered for the medical and nutritional management of a person who has
limited capacity to metabolize foodstuffs or certain nutrients contained in the
foodstuffs or who has other specific nutrient requirements as established by medical
evaluation.
(d) Essential to a person's optimal growth, health and metabolic homeostasis.
4. "Modified low protein foods" means foods that are all of the following:
(a) Formulated to be consumed or administered enterally under the supervision of a
physician who is licensed pursuant to title 32, chapter 13 or 17 or a registered nurse
practitioner who is licensed pursuant to title 32, chapter 15.
(b) Processed or formulated to contain less than one gram of protein per unit of
serving, but does not include a natural food that is naturally low in protein.
(c) Administered for the medical and nutritional management of a person who has
limited capacity to metabolize foodstuffs or certain nutrients contained in the
foodstuffs or who has other specific nutrient requirements as established by medical
evaluation.
(d) Essential to a person's optimal growth, health and metabolic homeostasis.
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