SB 1426

This bill requires the division 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 th is state by an MCO on or after January 1, 2026, to provide coverage for physician prescribed treatment, deemed medically necessary, of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-on s et neuropsychiatric syndrome (PANS). Such treatment must include antibiotics, medication, behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy. As used in this bill, an "MCO"" means a health maintenance organization, behavioral health organization, or managed health insurance issuer that participates in the TennCare program. PROHIBITIONS This bill prohibits the following:  Benefits provided under this bill from being 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.  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, 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 bill, 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 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. CODES FOR PANDAS AND PANS For billing and diagnosis purposes, this bill requires PANDAS and PANS to be coded as autoimmune encephalitis until the American Medical Asso ciation 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 a n d PANS, then this bill applies to patients with conditions under that new common name or code. ON APRIL 14, 2025, THE HOUSE ADOPTED AMENDMENT #1 AND PASSED HOUSE BILL 411, AS AMENDED. AMENDMENT #1 makes the following revisions:  Authorizes, instead of requires, the division 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 an MCO on or after January 1, 2026, to provide coverage for physician prescribed treatment, deemed medically necessary, of pediatric autoimmune neuropsychiatric disorders associated with PANDAS and PANS.  Authorizes, instead of requires, such treatment to include antibiotics, medication, behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.  Authorizes coverage of PANDAS and PANS to take into consideration, instead of requiring adherence 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.  Removes the provision prohibiting 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. ON APR IL 21, 2025, THE SENATE SUBSTITUTED HOUSE BILL 411 FOR SENATE BILL 1426, ADOPTED AMENDMENT #2, AND PASSED HOUSE BILL 411, AS AMENDED. AMENDMENT #2 names the bill ""Lucca's Law."""