HB 513

Abstract

State plan for medical assistance services and health insurance; pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome. Directs the Board of Medical Assistance Services to amend the state plan for medical assistance services to include a provision for payment of medical assistance for the prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) that includes payment for treatment using antimicrobials, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.The bill also requires each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services to provide coverage for the prophylaxis, diagnosis, and treatment of PANDAS and PANS. The bill requires such coverage to include coverage for treatment using antibiotics, medication, and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.The bill prohibits an insurer, corporation, or organization from (i) denying or delaying the coverage of PANDAS or PANS because the enrollee previously received treatment or because the enrollee was diagnosed with or received treatment for his condition under a different diagnostic name, including autoimmune encephalopathy; (ii) limiting coverage of immunomodulating therapies for the treatment of PANDAS or PANS in a manner that is inconsistent with the treatment guidelines developed by a consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of PANDAS or PANS that are accessible for medical professionals and are based on evidence of positive patient outcomes; (iii) requiring a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies for the treatment of PANDAS or PANS; or (iv) denying coverage for out-of-state treatment if the service is not available within the Commonwealth.