Insurance Coverage Pediatric Neuropsychiatric Syndrome

To the extent the coverage is not in addition to the benefits provided pursuant to the health insurance benchmark plan, the act requires all individual and group health benefit plans to provide health insurance coverage for pediatric acute-onset neuropsychiatric syndrome (PANS) and includes pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS).

The coverage provided for PANS and PANDAS must adhere to treatment recommended and be developed by a consortium of medical professionals convened to identify and publish clinical practice guidelines and evidence-based standards for the diagnosis and treatment of PANS and PANDAS. The coverage includes, among other treatments and therapies, antibiotics, medication and psychological and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy if certain conditions are met.

The mandatory coverage provision applies to large group policies and contracts issued or renewed in this state on or after January 1, 2025. For individual and small group policies and contracts, the division of insurance in the department of regulatory agencies (department) shall implement the coverage for individual and small group plans on or after January 1, 2026, if the federal department of health and human services (federal department) affirms the department's determination, or otherwise affirms, that the coverage does not require state defrayal of any increased costs for coverage of PANS and PANDAS or the department determines that the federal department's unreasonable delay precludes requiring defrayal.

APPROVED by Governor June 3, 2024

EFFECTIVE June 3, 2024
(Note: This summary applies to this bill as enacted.)