California § 1367.38 - A health care service plan contract issued, amended, or renewed on or after Janua

§ 1367.38. A health care service plan contract issued, amended, or renewed on or after Janua

(a) A health care service plan contract issued, amended, or renewed on or after January 1, 2025, shall provide coverage for the prophylaxis, diagnosis, and treatment of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) that is prescribed or ordered by the treating physician and surgeon and is medically necessary, as defined by current nationally recognized clinical practice guidelines by expert treating physicians published in peer-reviewed medical literature. Treatment for PANDAS and PANS that shall be covered includes antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy. (b) Coverage for PANDAS and PANS shall not be subject to a copayment, coinsurance, deductible, or other cost sharing that is greater than that applied to other benefits provided by the contract. (c) (1) A required authorization for PANDAS and PANS prophylaxis, diagnosis, or treatment shall be provided in a timely manner that is appropriate for the severity of an enrollee’s condition pursuant to Section 1367.03. (2) A health care service plan shall not deny or delay coverage for PANDAS or PANS therapies because the enrollee previously received treatment, including the same or similar treatment, for PANDAS or PANS, or because the enrollee was diagnosed with or received treatment for their condition under a different diagnostic name, including autoimmune encephalopathy. (3) A health care service plan shall not limit coverage of immunomodulating therapies for PANDAS or PANS in a manner that is inconsistent with the treatment recommendations pursuant to subdivision (d), and shall not require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies pursuant to this section. (d) Coverage for PANDAS and PANS shall adhere to the treatment recommendations delineated in current clinical practice guidelines published in peer-reviewed medical literature or put forth by organizations composed of expert treating clinicians. (e) For billing and diagnostic purposes, PANDAS and PANS shall be coded as autoimmune encephalitis until the American Medical Association and the federal Centers for Medicare and Medicaid Services create and assign a specific code or codes for PANDAS and PANS. After the creation of that code or codes, PANDAS and PANS may be coded as autoimmune encephalitis, PANDAS, or PANS. If PANDAS or PANS is known by a different common name in the future, it may be coded under that name and this section shall apply to that disorder or syndrome. (f) This section does not apply to a specialized health care service plan contract that covers dental or vision benefits or a Medicare supplement policy.