SENATE BILL NO. 1030
October 08, 2024, Introduced by Senators HERTEL, DAMOOSE and SINGH and referred to the
Committee on Finance, Insurance, and Consumer Protection.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
(MCL 500.100 to 500.8302) by adding section 3406pp.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
1 Sec. 3406pp. (1) A health insurance policy delivered, issued
2 for delivery, or renewed in this state after the effective date of
3 the amendatory act that added this section must provide coverage
4 for the prophylaxis, diagnosis, and treatment of pediatric
5 autoimmune neuropsychiatric disorders associated with streptococcal
6 infections and pediatric acute onset neuropsychiatric syndrome that
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1 is prescribed or ordered by a physician or provider, including, but
2 not limited to, antibiotics, medication and behavioral therapies to
3 manage neuropsychiatric symptoms, immunomodulating medicines,
4 plasma exchange, and the use of intravenous immunoglobulin therapy.
5 (2) Benefits under a health insurance policy subject to this
6 section must not be subject to any greater copayment, deductible,
7 or coinsurance than any other benefits provided by the insurer.
8 (3) A required authorization for pediatric autoimmune
9 neuropsychiatric disorders associated with streptococcal infections
10 and pediatric acute onset neuropsychiatric syndrome prophylaxis,
11 diagnosis, or treatment must be provided in a timely manner that is
12 appropriate for the severity of an insured's condition. Coverage
13 must be provided in a timely manner under standards for urgent
14 treatments.
15 (4) An insurer that delivers, issues for delivery, or renews
16 in this state a health insurance policy shall not deny or delay
17 coverage for pediatric autoimmune neuropsychiatric disorders
18 associated with streptococcal infections or pediatric acute onset
19 neuropsychiatric syndrome treatment or therapies under this section
20 because the insured previously received any treatment, including
21 the same or similar treatment, for pediatric autoimmune
22 neuropsychiatric disorders associated with streptococcal
23 infections, pediatric acute onset neuropsychiatric syndrome, or any
24 other diagnosed condition or because the insured was diagnosed with
25 or received treatment for the insured's condition under a different
26 diagnostic name, including, but not limited to, autoimmune
27 encephalopathy.
28 (5) An insurer that delivers, issues for delivery, or renews
29 in this state a health insurance policy shall not limit coverage of
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1 immunomodulating therapies for pediatric autoimmune
2 neuropsychiatric disorders associated with streptococcal infections
3 or pediatric acute onset neuropsychiatric syndrome in a manner that
4 is inconsistent with the treatment recommendations under subsection
5 (6) and shall not require a trial of therapies that treat only
6 neuropsychiatric symptoms before authorizing coverage of
7 immunomodulating therapies under this section, including, but not
8 limited to, intravenous immunoglobulin therapy.
9 (6) For the purposes of this section, when providing coverage
10 of pediatric autoimmune neuropsychiatric disorders associated with
11 streptococcal infections and pediatric acute onset neuropsychiatric
12 syndrome prescribed therapies and treatments, an insurer shall
13 adhere to the treatment recommendations developed by a medical
14 professional consortium convened for the purposes of researching,
15 identifying, and publishing clinical practice guidelines and
16 evidence-based standards for prophylaxis, diagnosis, and treatment
17 of the disorders or syndromes that are accessible for medical
18 professionals and are based on evidence of positive patient
19 outcomes. A review of coverage is considered reasonable only if it
20 references all peer-reviewed published standards of care
21 development by medical professionals with expertise in pediatric
22 autoimmune neuropsychiatric disorders associated with streptococcal
23 infections and pediatric acute onset neuropsychiatric syndrome
24 prophylaxis, diagnosis, and treatment.
25 (7) If an insured has filed an appeal with the department
26 because of being denied coverage for therapy or treatment under
27 this section, the department must refer and give deference to the
28 treatment recommendations developed by a medical professional
29 consortium convened for the purposes of researching, identifying,
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1 and publishing clinical practice guidelines and evidence-based
2 standards for prophylaxis, diagnosis, and treatment of pediatric
3 autoimmune neuropsychiatric disorders associated with streptococcal
4 infections and pediatric acute onset neuropsychiatric syndrome that
5 are accessible for medical professionals and are based on evidence
6 of positive patient outcomes.
7 (8) Coverage under this section for any form of therapy or
8 treatment that is prescribed or ordered by a physician or provider
9 must not be limited over a lifetime of an insured, except as
10 limited by policy period.
11 (9) For billing and diagnosis purposes, pediatric autoimmune
12 neuropsychiatric disorders associated with streptococcal infections
13 and pediatric acute onset neuropsychiatric syndrome must be coded
14 as autoimmune encephalopathy and coded as D89.89 (other specified
15 disorders involving the immune mechanism not otherwise specified)
16 per the National Center for Health Statistics and ICD-10-CM unless
17 the American Medical Association and the Centers for Medicare and
18 Medicaid Services create and assign a specific code for pediatric
19 autoimmune neuropsychiatric disorders associated with streptococcal
20 infections and pediatric acute onset neuropsychiatric syndrome. If
21 the American Medical Association and the Centers for Medicare and
22 Medicaid Services create and assign a specific code for pediatric
23 autoimmune neuropsychiatric disorders associated with streptococcal
24 infections and pediatric acute onset neuropsychiatric syndrome,
25 pediatric autoimmune neuropsychiatric disorders associated with
26 streptococcal infections and pediatric acute onset neuropsychiatric
27 syndrome may be coded as autoimmune encephalopathy, PANDAS, or
28 PANS. If the American Medical Association adopts the ICD-11-CM,
29 pediatric autoimmune neuropsychiatric disorders associated with
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1 streptococcal infections and pediatric acute onset neuropsychiatric
2 syndrome must be coded under 8E4A – paraneoplastic or autoimmune
3 disorders of the central nervous system, brain, or spinal cord.
4 (10) The amendatory act that added this section applies to
5 existing health insurance policies and health insurance policies
6 delivered, executed, issued, amended, adjusted, or renewed in this
7 state, or outside of this state if covering residents of this
8 state, beginning 90 dates after the date this amendatory act is
9 enacted into law.
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Statutes affected:
Senate Introduced Bill: 500.100, 500.8302