INTRODUCTION

The bill would require insurers in Michigan to cover treatment for pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Generally, PANS and PANDAS "are conditions characterized by a sudden and severe onset of obsessive-compulsive disorder (OCD) or restrictive eating disorder in children before puberty".¹ Symptoms are usually severe, unexpected, and can include compulsions, obsessions, and motor and vocal tics, among others.² In addition to required treatment, the bill would prohibit an insurer from subjecting PANDAS and PANS treatment to greater copayments, deductibles, or coinsurances than other benefits and require an insurer to adhere to treatment standards developed by a medical professional consortium convened for the purpose of developing treatment standards for PANS and PANDAS, among other authorization and treatment requirements.

PREVIOUS LEGISLATION

(This section does not provide a comprehensive account of previous legislative efforts on this subject matter.)

Senate Bill 447 is a reintroduction of Senate Bill 1030 of the 2023-2024 Legislative Session.

FISCAL IMPACT

The bill would have no fiscal impact on State or local government.

Proposed MCL 500.3406pp Legislative Analyst: Alex Krabill

Fiscal Analyst: Nathan Leaman

CONTENT

The bill would amend Chapter 34 (Disability Insurance Policies) of the Insurance Code to do the following:

-- Require a health insurance policy delivered, issued for delivery, or renewed in Michigan to provide coverage for the prophylaxis, diagnosis, and treatment of PANDAS and PANS that was prescribed or ordered by a physician or provider.

-- Prohibit benefits for PANDAS and PANS from being subject to any greater copayment, deductible, or coinsurance than other benefits provided by the insurer.

-- Require an authorization for PANDAS and PANS to be provided in a timely manner that was appropriate for the severity of the insured's condition and for urgent treatments.

-- Prohibit an insurer from denying or delaying coverage for PANDAS or PANS based on previously received treatment.

-- Prohibit an insurer from limiting coverage of immunomodulating therapies for PANDAS or PANS in a manner that was inconsistent with treatment recommendations within the bill.

-- Require an insurer to adhere to the treatment recommendations developed by a medical professional consortium convened for the purposes of setting practice guidelines for PANDAS and PANS.

-- Require the Department of Insurance and Financial Services (DIFS) to refer and give deference to the treatment recommendations developed by the medical professional consortium mentioned above in an insured's appeal.

-- Prohibit coverage for any prescribed form of therapy or treatment for PANDAS and PANS from being limited over a lifetime of an insured.

-- Specify the coding for PANDAS and PANS treatments.

-- Specify that the bill's provisions would apply to existing health insurance policies and health insurance policies delivered, executed, issued, amended, adjusted, or renewed in Michigan, or outside of Michigan if covering residents of Michigan, beginning 90 days after the bill's enactment.

Under the bill, a health insurance policy delivered, issued for delivery, or renewed in Michigan after the bill's effective date would have to provide coverage for the prophylaxis, diagnosis, and treatment of PANDAS and PANS that was prescribed or ordered by a physician or provider. The bill specifies that coverage would have to include antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and the use of intravenous immunoglobulin therapy.

Benefits under a health insurance policy subject to the bill's provisions could not be subject to any greater copayment, deductible, or coinsurance than any other benefits provided by the insurer. A required authorization for PANDAS and PANS prophylaxis, diagnosis, or treatment would have to be provided in a timely manner that was appropriate for the severity of an insured's condition. Coverage would have to be provided in a timely manner under standards for urgent treatments.

An insurer that delivered, issued for delivery, or renewed in Michigan a health insurance policy could not deny or delay coverage for PANDAS or PANS treatment or therapies because the insured previously received any treatment, including the same or similar treatment, for PANDAS, PANS, 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 autoimmune encephalopathy.

[1] National Institute of Health, "PANS and PANDAS: Questions and Answers", 2025.

An insurer that delivered, issued for delivery, or renewed in Michigan a health insurance policy could not limit coverage of immunomodulating therapies for PANDAS or PANS in a manner that was inconsistent with the treatment recommendations below. The insurer also could not require a trial of therapies that treated only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies, including intravenous immunoglobulin therapy.

When providing coverage of PANDAS and PANS prescribed therapies and treatments, an insurer would have to 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 were accessible for medical professionals and were based on evidence of positive patient outcomes. A review of coverage would be considered reasonable only if it referenced all peer-reviewed published standards of care development by medical professionals with expertise in PANDAS and PANS prophylaxis, diagnosis, and treatment.

If an insured had filed an appeal with DIFS because of being denied coverage for therapy or treatment, DIFS would have to 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 PANDAS and PANS that were accessible for medical professionals and were based on evidence of positive patient outcomes.

Coverage for any form of therapy or treatment that was prescribed or ordered by a physician or provider could not be limited over a lifetime of an insured, except as limited by policy period.

For billing and diagnosis purposes, PANDAS and PANS would have to 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 created and assigned a specific code for PANDAS and PANS. If the American Medical Association and the Centers for Medicare and Medicaid Services created and assigned a specific code for PANDAS and PANS, PANDAS and PANS could be coded as autoimmune encephalopathy, PANDAS, or PANS. If the American Medical Association adopted the ICD-11-CM, PANDAS and PANS would have to be coded under 8E4A – paraneoplastic or autoimmune disorders of the central nervous system, brain, or spinal cord.

The bill's provisions would apply to existing health insurance policies and health insurance policies delivered, executed, issued, amended, adjusted, or renewed in Michigan, or outside of Michigan if covering residents of Michigan, beginning 90 dates after the date the bill was enacted into law.

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This analysis was prepared by nonpartisan Senate staff for use by the Senate in its deliberations and does not constitute an official statement of legislative intent.