Today's Law As Amended


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AB-907 Coverage for PANDAS and PANS. (2023-2024)



As Amends the Law Today


SECTION 1.

 Section 1367.38 is added to the Health and Safety Code, to read:

1367.38.
 (a) A health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) that is prescribed or ordered by the treating physician and surgeon. Treatment for PANDAS and PANS that shall be covered includes antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.
(b) Coverage for PANDAS and PANS shall not be subject to a copayment, coinsurance, deductible, or other cost sharing that is greater than that applied to other benefits provided by the contract.
(c) (1) Any required authorization for PANDAS and PANS prophylaxis, diagnosis, or treatment shall be provided in a timely manner that is appropriate for the severity of an enrollee’s condition pursuant to Section 1367.03.
(2) A health care service plan shall not deny or delay coverage for PANDAS or PANS therapies because the enrollee previously received treatment, including the same or similar treatment, for PANDAS or PANS, or because the enrollee was diagnosed with or received treatment for their condition under a different diagnostic name, including autoimmune encephalopathy.
(3) A health care service plan shall not limit coverage of immunomodulating therapies for PANDAS or PANS in a manner that is inconsistent with the treatment recommendations pursuant to subdivision (d), and shall not require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies pursuant to this section.
(d) Coverage for PANDAS and PANS shall adhere to the treatment recommendations developed by a consortium of medical professionals convened to research, identify, and publish clinical practice guidelines and evidence-based standards for the diagnosis and treatment of those disorders.
(e) For billing and diagnostic purposes, PANDAS and PANS shall be coded as autoimmune encephalitis until the American Medical Association and the federal Centers for Medicare and Medicaid Services create and assign a specific code or codes for PANDAS and PANS. After the creation of that code or codes, PANDAS and PANS may be coded as autoimmune encephalitis, PANDAS, or PANS. If PANDAS or PANS is known by a different common name in the future, it may be coded under that name and this section shall apply to that disorder or syndrome.
(f) This section does not apply to a specialized health care service plan contract that covers dental or vision benefits or a Medicare supplement policy.

SEC. 2.

 Section 10123.38 is added to the Insurance Code, to read:

10123.38.
 (a) A health insurance policy issued, amended, or renewed on or after January 1, 2024, shall provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) that is prescribed or ordered by the treating physician and surgeon. Treatment for PANDAS and PANS that shall be covered includes antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.
(b) Coverage for PANDAS and PANS shall not be subject to a copayment, coinsurance, deductible, or other cost sharing that is greater than that applied to other benefits provided by the policy.
(c) (1) Any required authorization for PANDAS and PANS prophylaxis, diagnosis, or treatment shall be provided in a timely manner that is appropriate for the severity of an insured’s condition pursuant to Section 10133.54.
(2) A health insurer shall not deny or delay coverage for PANDAS or PANS therapies because the insured previously received treatment, including the same or similar treatment, for PANDAS or PANS, or because the insured was diagnosed with or received treatment for their condition under a different diagnostic name, including autoimmune encephalopathy.
(3) A health insurer shall not limit coverage of immunomodulating therapies for PANDAS or PANS in a manner that is inconsistent with the treatment recommendations pursuant to subdivision (d), and shall not require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies pursuant to this section.
(d) Coverage for PANDAS and PANS shall adhere to the treatment recommendations developed by a consortium of medical professionals convened to research, identify, and publish clinical practice guidelines and evidence-based standards for the diagnosis and treatment of those disorders.
(e) For billing and diagnostic purposes, PANDAS and PANS shall be coded as autoimmune encephalitis until the American Medical Association and the federal Centers for Medicare and Medicaid Services create and assign a specific code or codes for PANDAS and PANS. After the creation of that code or codes, PANDAS and PANS may be coded as autoimmune encephalitis, PANDAS, or PANS. If PANDAS or PANS is known by a different common name in the future, it may be coded under that name and this section shall apply to that disorder or syndrome.
(f) This section does not apply to a specialized health insurance policy that covers dental or vision benefits or a Medicare supplement policy.
SEC. 3.
 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.