Substitute House Bill No. 5374, effective January 1, 2027, introduces new health coverage mandates for specific health conditions, including Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections and Pediatric Acute-onset Neuropsychiatric Syndrome, requiring individual and group health insurance policies to cover related treatments, such as intravenous immunoglobulin therapy. The bill also mandates that health insurance policies covering chemotherapy provide coverage for scalp cooling systems, ensuring that the coverage is at least equivalent to Medicare standards and that out-of-pocket expenses are not more restrictive than for other benefits. High deductible health plans are exempt from certain deductible limits, and prior authorization for scalp cooling systems is permitted.

Additionally, the bill revises definitions related to infertility and prosthetic devices, removing previous exclusions and updating criteria for coverage. The definition of "infertility" now encompasses various medical and personal factors affecting conception, rather than solely focusing on the inability to conceive over a one-year period. Coverage for medically necessary infertility treatments, including in-vitro fertilization, is mandated for individuals who meet the new criteria, and the previous requirement of demonstrating an inability to conceive has been deleted. The bill ensures that individuals are not denied coverage for choosing to forego treatments deemed likely to be unsuccessful by their physician.

Statutes affected:
Raised Bill:
INS Joint Favorable Substitute:
File No. 242:
APP Joint Favorable:
Public Act No. 26-33: