HF 2314 (LSB 5783YH (1) 91)

HOUSE FILE 2314

BY  BARKER

A BILL FOR

An Act relating to health insurance coverage for specified pediatric autoimmune neuropsychiatric disorders and postinfectious autoimmune encephalopathy.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.37  Pediatric autoimmune neuropsychiatric disorders and associated conditions —— coverage.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Covered person” means the same as defined in section 514J.102.
   b.  “Health care professional” means the same as defined in section 514J.102.
   c.  “Health carrier” means the same as defined in section 514J.102.
   d.  “Pediatric acute-onset neuropsychiatric syndrome” or “PANS” means a clinically defined disorder characterized by the sudden onset of obsessive-compulsive symptoms or eating restrictions accompanied by two or more symptoms of either one or both of the following:
   (1)  Acute behavioral deterioration.
   (2)  Motor and sensory changes.
   e.  “Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections” or “PANDAS” means a term used to describe a subset of children and adolescents within the broader PANS classification.
   2.  a.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a health carrier that offers individual, group, or small group contracts, policies, or plans in this state that provide for third-party payment or prepayment of health or medical expenses shall offer coverage for the diagnosis and treatment of PANS, PANDAS, and postinfectious autoimmune encephalopathy as recommended by a covered person’s health care professional as medically necessary and that is consistent with the standard of medical care and protocols established in collaboration with the national institute of mental health, the children’s postinfectious autoimmune encephalopathy center of excellence, and the PANDAS physicians network. Treatment may include but is not limited to antibiotics, drugs and behavioral therapies to manage neuropsychiatric symptoms, plasma exchange, and immunoglobulin.
   b.  Coverage required under paragraph “a” shall not be denied or delayed because the covered person has received any treatment, including the same or similar treatment, for PANS, PANDAS, or postinfectious autoimmune encephalopathies.
   c.  Coverage required under paragraph “a” shall not be denied or delayed because the covered person has also been diagnosed with or receives treatment for a medical condition other than PANS, PANDAS, or postinfectious autoimmune encephalopathies.
   d.  Coverage required under paragraph “a” shall not be limited over a covered person’s lifetime unless by policy period, or because the covered person’s health care professional determines that the covered person is no longer benefiting from the treatment recommended by the health care professional.
   3.  This section shall not be construed to prohibit a health carrier from requesting treatment notes, and anticipated treatment duration outcome information, from a covered person’s health care professional.
   4.  a.  This section shall apply to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  A plan established for public employees pursuant to chapter 509A.
   b.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
   5.  The commissioner of insurance shall adopt rules pursuant to chapter 17A as necessary to administer this section.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to health insurance coverage for pediatric acute-onset neuropsychiatric syndrome (PANS), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), and postinfectious autoimmune encephalopathy.
   The bill defines “PANS” as a clinically defined disorder characterized by the sudden onset of obsessive-compulsive symptoms or eating restrictions accompanied by two or more symptoms of either one or both of acute behavioral deterioration and motor and sensory changes. “PANDAS” is defined as a term used to describe a subset of children and adolescents within the broader PANS classification.
   The bill requires a health carrier that offers individual, group, or small group contracts, policies, or plans in this state that provide for third-party payment or prepayment of health or medical expenses to offer coverage for the diagnosis and treatment of PANS, PANDAS, and postinfectious autoimmune encephalopathy as recommended by a covered person’s health care professional as medically necessary and that is consistent with the standard of medical care and protocols established in collaboration with the national institute of mental health, the children’s postinfectious autoimmune encephalopathy center of excellence, and the PANDAS physicians network. Treatment may include but is not limited to antibiotics, drugs and behavioral therapies to manage neuropsychiatric symptoms, plasma exchange, and immunoglobulin. Additional requirements concerning the coverage are detailed in the bill.
   The bill shall not be construed to prohibit a health carrier from requesting treatment notes, and anticipated treatment duration outcome information, from a covered person’s health care professional.
   The bill applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027, by the third-party payment providers enumerated in the bill. The bill specifies the types of specialized health-related insurance which are not subject to the bill’s coverage requirements.
   The commissioner of insurance is required to adopt rules to administer the bill.