SB5: SB5 Private Review Agents; health insurers to implement and maintain a program that allows for the selective application of reductions in prior authorization requirements; provide

This bill has two main parts. First, it requires every Georgia insurer that uses prior authorization (insurer pre-approval before a treatment is covered) to create a program that reduces those requirements for healthcare providers who perform well and follow evidence based medicine. Insurers choose their own criteria but must file a description of the program with the state Insurance Department every year starting no later than July 1, 2026. Second, the bill requires health insurance policies and the state health benefit plan (covering state and public employees, dependents, and retirees) to cover diagnosis, treatment, and monitoring of PANDAS and PANS, two related neuropsychiatric conditions that can appear suddenly in children, when treatment follows nationally recognized clinical guidelines. Insurers can apply normal deductibles and copays but cannot impose special extra costs just for these conditions. The insurance coverage rules apply to policies issued or renewed on or after July 1, 2025, and the state employee plan requirement begins January 1, 2026.

• Requires insurers using prior authorization to create a program that reduces those requirements for providers who meet performance and evidence based medicine criteria.
• Requires those insurers to file an annual report with the Georgia Department of Insurance describing the program, participation criteria, and covered services, starting no later than July 1, 2026.
• Requires health insurance policies issued or renewed after July 1, 2025 to cover diagnosis, treatment, and monitoring of PANDAS and PANS when supported by nationally recognized clinical practice guidelines.
• Requires the state health benefit plan for state and public employees to cover PANDAS and PANS treatment starting January 1, 2026.
• Allows insurers to apply normal deductibles and copays to PANDAS/PANS coverage but bans special extra charges that apply only to those conditions.
• Directs the Insurance Commissioner to write rules and regulations to implement both the prior authorization program and the PANDAS/PANS coverage requirements.

Health insurers and private review agents operating in Georgia, healthcare providers whose performance is measured for reduced prior authorization, families of children with PANDAS or PANS seeking treatment, and state and public employees, dependents, and retirees covered by the state health benefit plan.

Doctors who meet an insurer's performance standards could face fewer pre-approval hurdles before treating patients, potentially speeding up care. Families of children with PANDAS or PANS would gain a guaranteed right to coverage for diagnosis and treatment under standard cost-sharing, rather than facing denials or special extra charges.

• Section 1-1 adds O.C.G.A. § 33-46-20.1, requiring insurers using prior authorization to build a program reducing those requirements for higher-performing providers, with insurer discretion over criteria.
• Section 1-1 requires an annual filing to the Department of Insurance describing the program, participation criteria, covered procedures, and number of participating providers, due no later than July 1, 2026.
• Section 2-1 adds O.C.G.A. § 33-24-59.34, defining PANDAS and PANS and requiring health benefit policies issued or renewed on or after July 1, 2025 to cover related diagnosis, treatment, and monitoring.
• Section 2-1 bars insurers from imposing special deductibles, copays, or limits on PANDAS/PANS coverage beyond what applies to other covered benefits.
• Section 2-2 adds O.C.G.A. § 45-18-4.2, extending the same PANDAS/PANS coverage requirement to the state health benefit plan starting January 1, 2026.
• Section 3-1 sets the Act's effective date as July 1, 2025, applying to policies and contracts issued, delivered, or renewed on or after that date.

1. 2025-05-14Effective Date 2025-07-01
2. 2025-05-14Act 299
3. 2025-05-14Senate Date Signed by Governor (Senate)
4. 2025-04-10Senate Sent to Governor (Senate)
5. 2025-04-04Senate Agreed House Amend or Sub (Senate)
6. 2025-04-02House Passed/Adopted By Substitute (House)
7. 2025-04-02House Third Readers (House)
8. 2025-03-31House Committee Favorably Reported By Substitute (House)

• Kay Kirkpatrick (R, SD-032)Primary sponsor
• Larry Walker (R, SD-020)
• Ben Watson (R, SD-001)
• Chuck Hufstetler (R, SD-052)
• Ed Harbison (D, SD-015)
• Michael Rhett (D, SD-033)
• Lee Hawkins (R, HD-027)

1. PassedSenate voteFebruary 12, 2025

   51 yea, 1 nay (1 not voting, 3 absent)

   Passage: Senate Vote #47

2. PassedHouse voteApril 2, 2025

   169 yea, 2 nay (3 not voting, 6 absent)

   Passage: House Vote #378

3. PassedSenate voteApril 4, 2025

   52 yea, 0 nay (3 not voting, 1 absent)

   Agree To House Substitute: Senate Vote #478

• health insurance
• prior authorization
• PANDAS and PANS
• state employee benefits
• insurance regulation