HOUSE BILL 411
By Lynn
SENATE BILL 1426
By Watson
SB1426
000450
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AN ACT to amend Tennessee Code Annotated, Title 8;
Title 56 and Title 71, relative to pediatric medical
disorders.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
SECTION 1. Tennessee Code Annotated, Title 71, Chapter 5, Part 1, is amended by
adding the following as a new section:
(a) For the purpose of this section, "managed care organization" or "MCO"
means a health maintenance organization, behavioral health organization, or managed
health insurance issuer that participates in the TennCare program.
(b) The division of TennCare shall require every group health insurance contract,
and every group hospital or medical expense insurance policy, plan, and group policy
delivered, issued for delivery, amended, or renewed in this state by an MCO on or after
January 1, 2026, to provide coverage for physician prescribed treatment, deemed
medically necessary pursuant to ยง 71-5-144, of pediatric autoimmune neuropsychiatric
disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset
neuropsychiatric syndrome (PANS). Such treatment must include antibiotics,
medication, behavioral therapies to manage neuropsychiatric symptoms,
immunomodulating medicines, plasma exchange, and intravenous immunoglobulin
therapy. Benefits provided under this section are not subject to a greater co-payment,
deductible, or coinsurance than another similar benefit provided by the MCO. Coverage
authorization must be provided in a timely manner consistent with department of
commerce and insurance rules for urgent treatments adopted pursuant to the Uniform
Administrative Procedures Act, compiled in title 4, chapter 5.
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(c) A group or individual policy of accident and health insurance or managed
care must not deny or delay coverage for medically necessary treatment under this
section solely because the recipient previously received treatment, including the same or
similar treatment, for PANDAS or PANS, or because the recipient has been diagnosed
with or received treatment for their condition under a different diagnostic name, such as
autoimmune encephalopathy. For the purposes of this section, coverage of PANDAS
and PANS must adhere to the treatment recommendations developed by a medical
professional consortium convened for the purposes of researching, identifying, and
publishing best practice standards for diagnosis and treatment of such disorders that are
accessible for medical professionals and are based on evidence of positive patient
outcomes. Coverage for a form of medically necessary treatment must not be limited
over the lifetime of a recipient or by the duration of a policy period. This section does not
prevent an MCO from requesting treatment notes and anticipated duration of treatment
and outcomes.
(d) For billing and diagnosis purposes, PANDAS and PANS must be coded as
autoimmune encephalitis until the American Medical Association and the centers for
medicare and medicaid services create and assign a specific code for PANDAS and
PANS. Thereafter, PANDAS and PANS may be coded as autoimmune encephalitis,
PANDAS, or PANS. If a new common name or code is utilized for PANDAS and PANS,
then this section applies to patients with conditions under that new common name or
code.
SECTION 2. This act takes effect upon becoming a law, the public welfare requiring it.