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Senate
File
242
-
Introduced
SENATE
FILE
242
BY
SWEENEY
A
BILL
FOR
An
Act
relating
to
health
insurance
coverage
for
specified
1
pediatric
autoimmune
neuropsychiatric
disorders
and
2
postinfectious
autoimmune
encephalopathy.
3
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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Section
1.
NEW
SECTION
.
514C.37
Pediatric
autoimmune
1
neuropsychiatric
disorders
and
associated
conditions
——
coverage.
2
1.
As
used
in
this
section,
unless
the
context
otherwise
3
requires:
4
a.
“Covered
person”
means
the
same
as
defined
in
section
5
514J.102.
6
b.
“Health
care
professional”
means
the
same
as
defined
in
7
section
514J.102.
8
c.
“Health
carrier”
means
the
same
as
defined
in
section
9
514J.102.
10
d.
“Pediatric
acute-onset
neuropsychiatric
syndrome”
or
11
“PANS”
means
a
clinically
defined
disorder
characterized
by
12
the
sudden
onset
of
obsessive-compulsive
symptoms
or
eating
13
restrictions
accompanied
by
two
or
more
symptoms
of
either
one
14
or
both
of
the
following:
15
(1)
Acute
behavioral
deterioration.
16
(2)
Motor
and
sensory
changes.
17
e.
“Pediatric
autoimmune
neuropsychiatric
disorders
18
associated
with
streptococcal
infections”
or
“PANDAS”
means
a
19
term
used
to
describe
a
subset
of
children
and
adolescents
20
within
the
broader
PANS
classification.
21
2.
a.
Notwithstanding
the
uniformity
of
treatment
22
requirements
of
section
514C.6,
a
health
carrier
that
offers
23
individual,
group,
or
small
group
contracts,
policies,
or
24
plans
in
this
state
that
provide
for
third-party
payment
25
or
prepayment
of
health
or
medical
expenses
shall
offer
26
coverage
for
the
diagnosis
and
treatment
of
PANS,
PANDAS,
27
and
postinfectious
autoimmune
encephalopathy
as
recommended
28
by
a
covered
person’s
health
care
professional
as
medically
29
necessary
and
that
is
consistent
with
the
standard
of
30
medical
care
and
protocols
established
in
collaboration
31
with
the
national
institute
of
mental
health,
the
children’s
32
postinfectious
autoimmune
encephalopathy
center
of
excellence,
33
and
the
PANDAS
physicians
network.
Treatment
may
include
but
34
is
not
limited
to
antibiotics,
drugs
and
behavioral
therapies
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242
to
manage
neuropsychiatric
symptoms,
plasma
exchange,
and
1
immunoglobulin.
2
b.
Coverage
required
under
paragraph
“a”
shall
not
be
3
denied
or
delayed
because
the
covered
person
has
received
any
4
treatment,
including
the
same
or
similar
treatment,
for
PANS,
5
PANDAS,
or
postinfectious
autoimmune
encephalopathies.
6
c.
Coverage
required
under
paragraph
“a”
shall
not
be
denied
7
or
delayed
because
the
covered
person
has
also
been
diagnosed
8
with
or
receives
treatment
for
a
medical
condition
other
than
9
PANS,
PANDAS,
or
postinfectious
autoimmune
encephalopathies.
10
d.
Coverage
required
under
paragraph
“a”
shall
not
11
be
limited
over
a
covered
person’s
lifetime
unless
by
12
policy
period,
or
because
the
covered
person’s
health
care
13
professional
determines
that
the
covered
person
is
no
longer
14
benefiting
from
the
treatment
recommended
by
the
health
care
15
professional.
16
3.
This
section
shall
not
be
construed
to
prohibit
a
health
17
carrier
from
requesting
treatment
notes,
and
anticipated
18
treatment
duration
outcome
information,
from
a
covered
person’s
19
health
care
professional.
20
4.
a.
This
section
shall
apply
to
the
following
classes
21
of
third-party
payment
provider
contracts,
policies,
or
plans
22
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
23
state
on
or
after
January
1,
2026:
24
(1)
Individual
or
group
accident
and
sickness
insurance
25
providing
coverage
on
an
expense-incurred
basis.
26
(2)
An
individual
or
group
hospital
or
medical
service
27
contract
issued
pursuant
to
chapter
509,
514,
or
514A.
28
(3)
An
individual
or
group
health
maintenance
organization
29
contract
regulated
under
chapter
514B.
30
(4)
A
plan
established
for
public
employees
pursuant
to
31
chapter
509A.
32
b.
This
section
shall
not
apply
to
accident-only,
33
specified
disease,
short-term
hospital
or
medical,
hospital
34
confinement
indemnity,
credit,
dental,
vision,
Medicare
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242
supplement,
long-term
care,
basic
hospital
and
medical-surgical
1
expense
coverage
as
defined
by
the
commissioner,
disability
2
income
insurance
coverage,
coverage
issued
as
a
supplement
3
to
liability
insurance,
workers’
compensation
or
similar
4
insurance,
or
automobile
medical
payment
insurance.
5
5.
The
commissioner
of
insurance
shall
adopt
rules
pursuant
6
to
chapter
17A
as
necessary
to
administer
this
section.
7
EXPLANATION
8
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
9
the
explanation’s
substance
by
the
members
of
the
general
assembly.
10
This
bill
relates
to
health
insurance
coverage
for
11
pediatric
acute-onset
neuropsychiatric
syndrome
(PANS),
12
pediatric
autoimmune
neuropsychiatric
disorders
associated
13
with
streptococcal
infections
(PANDAS),
and
postinfectious
14
autoimmune
encephalopathy.
15
The
bill
defines
“PANS”
as
a
clinically
defined
disorder
16
characterized
by
the
sudden
onset
of
obsessive-compulsive
17
symptoms
or
eating
restrictions
accompanied
by
two
or
18
more
symptoms
of
either
one
or
both
of
acute
behavioral
19
deterioration
and
motor
and
sensory
changes.
“PANDAS”
is
20
defined
as
a
term
used
to
describe
a
subset
of
children
and
21
adolescents
within
the
broader
PANS
classification.
22
The
bill
requires
a
health
carrier
that
offers
individual,
23
group,
or
small
group
contracts,
policies,
or
plans
in
this
24
state
that
provide
for
third-party
payment
or
prepayment
of
25
health
or
medical
expenses
to
offer
coverage
for
the
diagnosis
26
and
treatment
of
PANS,
PANDAS,
and
postinfectious
autoimmune
27
encephalopathy
as
recommended
by
a
covered
person’s
health
care
28
professional
as
medically
necessary
and
that
is
consistent
29
with
the
standard
of
medical
care
and
protocols
established
in
30
collaboration
with
the
national
institute
of
mental
health,
the
31
children’s
postinfectious
autoimmune
encephalopathy
center
of
32
excellence,
and
the
PANDAS
physicians
network.
Treatment
may
33
include
but
is
not
limited
to
antibiotics,
drugs
and
behavioral
34
therapies
to
manage
neuropsychiatric
symptoms,
plasma
exchange,
35
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4
S.F.
242
and
immunoglobulin.
Additional
requirements
concerning
the
1
coverage
are
detailed
in
the
bill.
2
The
bill
shall
not
be
construed
to
prohibit
a
health
carrier
3
from
requesting
treatment
notes,
and
anticipated
treatment
4
duration
outcome
information,
from
a
covered
person’s
health
5
care
professional.
6
The
bill
applies
to
third-party
payment
provider
contracts,
7
policies,
or
plans
delivered,
issued
for
delivery,
continued,
8
or
renewed
in
this
state
on
or
after
January
1,
2026,
by
the
9
third-party
payment
providers
enumerated
in
the
bill.
The
bill
10
specifies
the
types
of
specialized
health-related
insurance
11
which
are
not
subject
to
the
bill’s
coverage
requirements.
12
The
commissioner
of
insurance
is
required
to
adopt
rules
to
13
administer
the
bill.
14
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