SB 475
Department of Legislative Services
Maryland General Assembly
2020 Session
FISCAL AND POLICY NOTE
Enrolled - Revised
Senate Bill 475 (Senator Sydnor, et al.)
Finance Health and Government Operations
Health Insurance - Pediatric Autoimmune Neuropsychiatric Disorders -
Coverage
This bill requires an insurer, nonprofit health service plan, or health maintenance
organization (collectively known as carriers) to provide coverage for medically necessary
diagnosis, evaluation, and treatment of pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections (PANDAS) and pediatric acute onset
neuropsychiatric syndrome (PANS), including the use of intravenous immunoglobulin
therapy (IVIG). Beginning January 1, 2021, Medicaid, subject to the limitations of the State
budget, must provide similar coverage for eligible program recipients. A carrier and
Medicaid are not required to cover rituximab unless the U.S. Food and Drug
Administration (FDA) approves it for the treatment of PANDAS and PANS. The bill also
specifies how PANDAS and PANS must be coded for billing and diagnosis purposes. The
bill takes effect January 1, 2021, and applies to all policies, contracts, and health
benefit plans issued, delivered, or renewed in the State on or after that date.
Fiscal Summary
State Effect: Minimal increase in special fund revenues for the Maryland Insurance
Administration (MIA) in FY 2021 from the $125 rate and form filing fee. Review of form
filings can likely be handled with existing budgeted resources. No effect on Medicaid or
the State Employee and Retiree Health and Welfare Benefits Program (State plan) at this
time, as discussed below.
Local Effect: To the extent the mandate increases the cost of health insurance,
expenditures may increase for local governments that purchase fully insured medical plans.
Revenues are not affected.
Small Business Effect: Potential minimal.
 Analysis
Bill Summary: A carrier may impose annual deductibles, copayments, or coinsurance on
the required coverage if they are not greater than those imposed by the carrier for similar
coverage under the same health insurance policy or contract. PANDAS and PANS must be
coded as autoimmune encephalitis for billing and diagnosis purposes. If the American
Medical Association and the federal Centers for Medicare and Medicaid Services create
and assign a specific code for PANDAS or PANS for billing and diagnosis purposes,
PANDAS and PANS may be coded as autoimmune encephalitis, PANDAS, or PANS.
Current Law: Under Maryland law, there are more than 50 mandated health insurance
benefits that certain carriers must provide to their enrollees. The federal Patient Protection
and Affordable Care Act requires nongrandfathered health plans to cover 10 essential
health benefits (EHBs), which include items and services in the following categories:
(1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity
and newborn care; (5) mental health and substance use disorder services; including
behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative
services and devices; (8) laboratory services; (9) preventive and wellness services and
chronic disease management; and (10) pediatric services, including dental and vision care.
Under § 31-116 of the Maryland Insurance Article, EHBs must be included in the State
benchmark plan and, not withstanding any other benefits mandated by State law, must be
the benefits required in (1) all individual health benefit plans and health benefit plans
offered to small employers (except for grandfathered health plans) offered outside the
Maryland Health Benefit Exchange (MHBE) and (2) all qualified health plans offered in
MHBE.
Background: According to the National Institute of Mental Health (NIMH), a child may
be diagnosed with PANDAS when obsessive compulsive disorder (OCD) and/or
tic disorders suddenly either appear or worsen following a strep infection. Symptoms are
usually dramatic, happen “overnight and out of the blue,” and can include motor and/or
vocal tics, obsessions and/or compulsions, anxiety, and irritability. The diagnostic criteria
for PANDAS include (1) presence of OCD and/or a tic disorder; (2) pediatric onset of
symptoms (age three years to puberty); (3) episodic course of symptom severity;
(4) association with group A Beta-hemolytic streptococcal infection; (5) association with
neurological abnormalities (physical hyperactivity or unusual, jerky movements that are
not in the child’s control); and (6) very abrupt onset or worsening of symptoms.
PANS includes all cases of acute onset OCD, not just those associated with streptococcal
infection. PANS diagnostic criteria include (1) abrupt, dramatic onset of OCD or severely
restricted food intake; (2) concurrent neuropsychiatric symptoms with similarly severe and
acute onset (such as anxiety, extreme mood swings, irritability, aggression, behavioral
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regression, deterioration in school performance, sensory or motor abnormalities, or somatic
signs); and (3) symptoms not better explained by a known neurologic or medical disorder.
The PANDAS Network estimates that PANDAS/PANS affects as many as 1 in
200 children.
In 2017, NIMH published comprehensive treatment recommendations for PANDAS and
PANS. The recommendations include three levels: (1) psychiatric and behavioral
interventions; (2) use of immunomodulatory therapies (including IVIG for moderate to
severe cases if antibiotic therapy fails); and (3) treatment and prevention of infections.
IVIG is an intravenous pooled blood product comprising immunoglobulins used in treating
immune deficiencies, encephalitis, and other medical conditions. According to the
PANDAS Physicians Network, IVIG currently has FDA indications for the treatment of
Kawasaki disease, idiopathic thrombocytopenic purpura, and other immune-mediated
diseases of childhood. It is not yet indicated for treatment of PANDAS. However, IVIG has
been shown to decrease symptom severity and shorten the course of illness in
PANDAS and is endorsed for treating PANDAS by a consortium of physicians and
researchers.
Rituximab is a medication used to treat certain autoimmune diseases such as rheumatoid
arthritis and cancers such as non-Hodgkin’s lymphoma and chronic lymphocytic leukemia.
It is not FDA-approved for the treatment of PANDAS or PANS.
To date, five states (Arkansas, Delaware, Illinois, Minnesota, and New Hampshire)
mandate insurance coverage for treatment of PANDAS/PANS, including the use of IVIG.
State Fiscal Effect:
Maryland Medicaid
Maryland Medicaid currently provides coverage for medically necessary services,
including treatment of PANDAS/PANS. However, under federal Early and Periodic
Screening, Diagnostic, and Treatment guidelines, Medicaid is not required to cover
experimental or investigational treatments or services. As such, the State does not cover
them for any reason. Medicaid advises that, at this time, as IVIG has not been
FDA-approved as a treatment for PANDAS/PANS and is considered experimental, it
would not be covered by Medicaid.
State Employee and Retiree Health and Welfare Benefits Program
The State plan is largely self-insured for its medical contracts and, as such, with the
exception of one fully insured integrated health model medical plan (Kaiser), is not subject
SB 475/ Page 3
to this mandate. However, the State plan generally provides coverage for mandated health
insurance benefits. According to the Department of Budget and Management (DBM), all
carriers participating in the State plan currently provide coverage for treatment of
PANDAS/PANS. However, as with Medicaid, DBM has previously advised that medical
plans in the State plan would not cover IVIG for PANDAS/PANS until it is FDA-approved
for these conditions and no longer considered experimental.
Potential Additional Costs
To the extent IVIG becomes FDA-approved for PANDAS/PANS, Medicaid and State plan
expenditures increase by an indeterminate amount. According to a 2015 analysis of similar
legislation proposed in Massachusetts, the total cost of IVIG therapy (based on 2012 claims
data) was $7,059 per treatment. The analysis concluded that requiring coverage for
treatment of PANDAS/PANS by fully insured health plans in Massachusetts would result
in an average annual increase, over five years, to the typical member’s monthly health
insurance premiums of between $0.003 (0.001%) and $0.039 (0.008%) per year.
Additional Comments: According to MIA, the bill establishes a new mandated benefit
for the large group market and individual grandfathered market only.
Additional Information
Prior Introductions: HB 15 of 2019, a similar bill, received a hearing in the House Health
and Government Operations Committee and was subsequently withdrawn.
Designated Cross File: HB 447 (Delegate Carr, et al.) - Health and Government
Operations.
Information Source(s): Department of Budget and Management; Maryland Department
of Health; Maryland Health Benefit Exchange; Maryland Insurance Administration;
Department of Legislative Services
Fiscal Note History: First Reader - February 5, 2020
rh/ljm Third Reader - March 16, 2020
Enrolled - April 1, 2020
Revised - Amendment(s) - April 1, 2020
Analysis by: Jennifer B. Chasse Direct Inquiries to:
(410) 946-5510
(301) 970-5510
SB 475/ Page 4


Statutes affected:
Text - First - Health Insurance - Pediatric Autoimmune Neuropsychiatric Disorders - Coverage: 15-103 Health General, 15-855 Health General
Text - Third - Health Insurance - Pediatric Autoimmune Neuropsychiatric Disorders - Coverage: 15-103 Health General, 15-855 Health General
Text - Enrolled - Health Insurance - Pediatric Autoimmune Neuropsychiatric Disorders - Coverage: 15-103 Health General, 15-855 Insurance