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: 4 TLSB 2577XS (2) 91 nls/ko
S.F. 242 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 persons 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 childrens 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 35 -1- LSB 2577XS (2) 91 nls/ko 1/ 4
S.F. 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 persons lifetime unless by 12 policy period, or because the covered persons 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 persons 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 35 -2- LSB 2577XS (2) 91 nls/ko 2/ 4
S.F. 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 explanations 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 persons 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 childrens 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 -3- LSB 2577XS (2) 91 nls/ko 3/ 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 persons 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 bills coverage requirements. 12 The commissioner of insurance is required to adopt rules to 13 administer the bill. 14 -4- LSB 2577XS (2) 91 nls/ko 4/ 4