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As Introduced
136th
General Assembly
Regular
Session
H. B. No. 831
2025-2026
Representative Daniels
Cosponsor: Representative Young
To
amend
section
3902.50
and to enact sections 5.22108,
3902.65
,
and
5164.094
of the Revised Code
to
require health plan issuers and the Medicaid program to cover
treatments and services related to Pediatric Autoimmune
Neuropsychiatric Disorders Associated with Streptococcal Infections
and Pediatric Acute-onset Neuropsychiatric Syndrome.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section
1.
That
section
3902.50
be amended and sections 5.22108,
3902.65
,
and
5164.094
of the Revised Code be enacted to read as follows:
Sec.
5.22108.
The
ninth day of October shall be designated "PANDAS and PANS
Awareness Day," referring to pediatric autoimmune
neuropsychiatric disorders associated with streptococcal infections,
commonly referred to as PANDAS, and pediatric acute-onset
neuropsychiatric syndrome, commonly referred to as PANS.
Sec.
3902.50.
As
used in sections 3902.50 to 3902.72 of the Revised Code:
(A)
"Ambulance" has the same meaning as in section 4765.01 of
the Revised Code.
(B)
"Clinical laboratory services" has the same meaning as in
section 4731.65 of the Revised Code.
(C)
"Cost sharing" means the cost to a covered person under a
health benefit plan according to any copayment, coinsurance,
deductible, or other out-of-pocket expense requirement.
(D)
"Covered" or "coverage" means the provision of
benefits related to health care services to a covered person in
accordance with a health benefit plan.
(E)
"Covered person," "health benefit plan," "health
care services," and "health plan issuer" have the same
meanings as in section 3922.01 of the Revised Code.
(F)
"Drug" has the same meaning as in section 4729.01 of the
Revised Code.
(G)
"Emergency facility" has the same meaning as in section
3701.74 of the Revised Code.
(H)
"Emergency services" means all of the following as
described in 42 U.S.C. 1395dd:
(1)
Medical screening examinations undertaken to determine whether an
emergency medical condition exists;
(2)
Treatment necessary to stabilize an emergency medical condition;
(3)
Appropriate transfers undertaken prior to an emergency medical
condition being stabilized.
(I)
"Health care practitioner" has the same meaning as in
section 3701.74 of the Revised Code.
(J)
"Pharmacy benefit manager" has the same meaning as in
section 3959.01 of the Revised Code.
(K)
"Prior authorization requirement" means any practice
implemented by a health plan issuer in which coverage of a health
care service, device, or drug is dependent upon a covered person or a
provider obtaining approval from the health plan issuer prior to the
service, device, or drug being performed, received, or prescribed, as
applicable. "Prior authorization requirement" includes
prospective or utilization review procedures conducted prior to
providing a health care service, device, or drug.
(L)
"Step
therapy protocol" has the same meaning as in section 3901.83 of
the Revised Code.
(M)
"Unanticipated
out-of-network care" means health care services, including
clinical laboratory services, that are covered under a health benefit
plan and that are provided by an out-of-network provider when either
of the following conditions applies:
(1)
The covered person did not have the ability to request such services
from an in-network provider.
(2)
The services provided were emergency services.
Sec.
3902.65.
(A)
As used in this section, "diagnostic evaluation" includes
all testing and services appropriate for any class of medical,
neurological, or immune-mediated disorders, including autoimmune
encephalitis.
(B)
Notwithstanding section 3901.71 of the Revised Code, a health benefit
plan issued, delivered, or renewed on or after the effective date of
this section shall provide coverage for the screening, diagnosis, and
treatment of pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections, commonly referred to as
PANDAS, and pediatric acute onset neuropsychiatric syndrome, commonly
referred to as PANS.
(C)
A health plan issuer shall not apply a cost-sharing requirement to
the coverage required under division (B) of this section that is less
favorable than the cost-sharing requirement that applies
substantially to all medical and surgical benefits provided under the
health benefit plan.
(D)
Benefits required under division (B) of this section shall cover, at
minimum, all of the following:
(1)
Comprehensive diagnostic evaluation, symptomatic relief, and related
services, including laboratory, radiology, psychiatric, and
behavioral services;
(2)
Immunomodulatory therapies, including all of the following:
(a)
Immunoglobulin therapy, including both high dose and low dose
infusions, as well as the cost of related medications,
administration, and monitoring;
(b)
Corticosteroids;
(c)
Plasmapheresis;
(d)
Rituxmab or similar products.
(3)
Antimicrobial treatment, including antibiotics and antivirals;
(4)
Therapeutic care, including services provided by a speech therapist,
speech-language pathologist, occupational therapist, or physical
therapist licensed or certified in the state in which the therapist
practices.
(E)(1)
The coverage required under division (B) of this section shall not be
subject to either a step therapy protocol or a prior authorization
requirement.
(2)
The coverage required under division (B) of this section shall not be
contingent upon either of the following:
(a)
A patient's symptoms meeting a specified threshold of severity;
(b)
A patient having a specified immunodeficiency status.
(F)
If, at any time, this state is required to defray the cost of any
coverage required under division (B) of this section, pursuant to any
provision of the "Patient Protection and Affordable Care Act of
2010," Pub. L. No. 111-148, including 42 U.S.C. 18031(d)(3)(B),
or any successor provision, or pursuant to any rules or regulations
promulgated, or any opinion, guidance, or other action made, by the
secretary of the United States department of health and human
services, or its successor agency, then the requirement made under
division (B) of this section shall be inoperative, other than any
such coverage authorized under 42 U.S.C. 1396a, and the state shall
not assume any obligation for the cost of coverage required under
division (B) of this section.
Sec.
5164.094.
(A)
As used in this section:
(1)
"Diagnostic evaluation" includes all testing and services
appropriate for any class of medical, neurological, or
immune-mediated disorders, including autoimmune encephalitis.
(2)
"Prior authorization requirement" has the same meaning as
in section 5160.34 of the Revised Code.
(3)
"Step therapy protocol" has the same meaning as in section
5164.7512 of the Revised Code.
(B)
The medicaid program shall provide coverage for the screening,
diagnosis, and treatment of pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections, commonly referred
to as PANDAS, and pediatric acute-onset neuropsychiatric syndrome,
commonly referred to as PANS.
(C)
The medicaid program shall not institute a cost-sharing requirement
under section 5162.20 of the Revised Code to the coverage required
under division (B) of this section that is less favorable than the
cost-sharing requirement that applies substantially to all medical
and surgical benefits provided under the health benefit plan.
(D)
Benefits required under division (B) of this section shall cover, at
a minimum, all of the following:
(1)
Comprehensive diagnostic evaluation, symptomatic relief, and related
services, including laboratory, radiology, psychiatric, and
behavioral services;
(2)
Immunomodulatory therapies, including all of the following:
(a)
Immunoglobulin therapy, including both high dose and low dose
infusions, as well as the cost of related medications,
administration, and monitoring;
(b)
Corticosteroids;
(c)
Plasmapheresis;
(d)
Rituxmab or similar products.
(3)
Antimicrobial treatment, including antibiotics and antivirals;
(4)
Therapeutic care, including services provided by a speech therapist,
speech-language pathologist, occupational therapist, or physical
therapist licensed or certified in the state in which the therapist
practices.
(E)(1)
The coverage required under division (B) of this section shall not be
subject to either a step therapy protocol or a prior authorization
requirement.
(2)
The coverage required under division (B) of this section shall not be
contingent upon either of the following:
(a)
A patient's symptoms meeting a specified threshold of severity;
(b)
A patient having a specified immunodeficiency status.
(F)
If, at any time, this state is required to defray the cost of any
coverage required under division (B) of this section, pursuant to any
provision of the "Patient Protection and Affordable Care Act of
2010," Pub. L. No. 111-148, including 42 U.S.C. 18031(d)(3)(B),
or any successor provision, or pursuant to any rules or regulations
promulgated, or any opinion, guidance, or other action made, by the
secretary of the United States department of health and human
services, or its successor agency, then the requirement made under
division (B) of this section shall be inoperative, other than any
such coverage authorized under 42 U.S.C. 1396a, and the state shall
not assume any obligation for the cost of coverage required under
division (B) of this section.
Section
2.
That
existing
section
3902.50
of the Revised Code
is
hereby
repealed.