Amends TCA Title 8; Title 56 and Title 71.

This bill requires the bureau of TennCare to 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 a health maintenance organization, behavioral health organization, or managed health insurance issuer that participates in the TennCare program ("MCO") on or after January 1, 2025, to provide coverage for physician prescribed treatment, deemed medically necessary, of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS).<br /> <br /> This bill requires the treatment to include, at a minimum, antibiotics, medication, behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy. This bill prohibits benefits provided under this bill from being subject to a greater co-payment, deductible, or coinsurance than another similar benefit provided by the MCO. This bill requires coverage authorization to be provided in a timely manner consistent with department of commerce and insurance rules for urgent treatments.<br /> <br /> This bill prohibits a group or individual policy of accident and health insurance or managed care from denying or delaying coverage for medically necessary treatment under this bill solely because the recipient previously received treatment for PANDAS or PANS, or because the recipient has been diagnosed with or received treatment for their condition under a different diagnostic name. This bill requires coverage of PANDAS and PANS to 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. This bill prohibits coverage for a form of medically necessary treatment from being limited over the lifetime of a recipient, or by the duration of a policy period. However, this bill does not prevent an MCO from requesting treatment notes and anticipated duration of treatment and outcomes.<br /> <br /> This bill requires, for billing and diagnosis purposes, that PANDAS and PANS 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. However, if a new common name or code is utilized for PANDAS and PANS, then this bill, at such time, applies to patients with conditions under such new common name or code.<br />