Bill Text: MI SB1030 | 2023-2024 | 102nd Legislature | Introduced
Bill Title: Insurance: insurers; coverage for certain pediatric autoimmune neuropsychiatric disorders; require. Amends 1956 PA 218 (MCL 500.100 - 500.8302) by adding sec. 3406pp.
Spectrum: Slight Partisan Bill (Democrat 2-1)
Status: (Introduced) 2024-10-08 - Referred To Committee On Finance, Insurance, And Consumer Protection [SB1030 Detail]
Download: Michigan-2023-SB1030-Introduced.html
SENATE BILL NO. 1030
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:
Sec. 3406pp. (1) A health insurance policy delivered, issued for delivery, or renewed in this state after the effective date of the amendatory act that added this section must provide coverage for the prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome that is prescribed or ordered by a physician or provider, including, but not limited to, antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and the use of intravenous immunoglobulin therapy.
(2) Benefits under a health insurance policy subject to this section must not be subject to any greater copayment, deductible, or coinsurance than any other benefits provided by the insurer.
(3) A required authorization for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome prophylaxis, diagnosis, or treatment must be provided in a timely manner that is appropriate for the severity of an insured's condition. Coverage must be provided in a timely manner under standards for urgent treatments.
(4) An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall not deny or delay coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or pediatric acute onset neuropsychiatric syndrome treatment or therapies under this section because the insured previously received any treatment, including the same or similar treatment, for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, pediatric acute onset neuropsychiatric syndrome, or any other diagnosed condition or because the insured was diagnosed with or received treatment for the insured's condition under a different diagnostic name, including, but not limited to, autoimmune encephalopathy.
(5) An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall not limit coverage of immunomodulating therapies for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or pediatric acute onset neuropsychiatric syndrome in a manner that is inconsistent with the treatment recommendations under subsection (6) and shall not require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies under this section, including, but not limited to, intravenous immunoglobulin therapy.
(6) For the purposes of this section, when providing coverage of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome prescribed therapies and treatments, an insurer shall adhere to the treatment recommendations developed by a medical professional consortium convened for the purposes of researching, identifying, and publishing clinical practice guidelines and evidence-based standards for prophylaxis, diagnosis, and treatment of the disorders or syndromes that are accessible for medical professionals and are based on evidence of positive patient outcomes. A review of coverage is considered reasonable only if it references all peer-reviewed published standards of care development by medical professionals with expertise in pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome prophylaxis, diagnosis, and treatment.
(7) If an insured has filed an appeal with the department because of being denied coverage for therapy or treatment under this section, the department must refer and give deference to the treatment recommendations developed by a medical professional consortium convened for the purposes of researching, identifying, and publishing clinical practice guidelines and evidence-based standards for prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome that are accessible for medical professionals and are based on evidence of positive patient outcomes.
(8) Coverage under this section for any form of therapy or treatment that is prescribed or ordered by a physician or provider must not be limited over a lifetime of an insured, except as limited by policy period.
(9) For billing and diagnosis purposes, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome must be coded as autoimmune encephalopathy and coded as D89.89 (other specified disorders involving the immune mechanism not otherwise specified) per the National Center for Health Statistics and ICD-10-CM unless the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. If the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome may be coded as autoimmune encephalopathy, PANDAS, or PANS. If the American Medical Association adopts the ICD-11-CM, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome must be coded under 8E4A – paraneoplastic or autoimmune disorders of the central nervous system, brain, or spinal cord.
(10) The amendatory act that added this section applies to existing health insurance policies and health insurance policies delivered, executed, issued, amended, adjusted, or renewed in this state, or outside of this state if covering residents of this state, beginning 90 dates after the date this amendatory act is enacted into law.
