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

25 LC 52 0855S Senate Bill 5 By: Senators Kirkpatrick of the 32nd, Walker III of the 20th, Watson of the 1st, Hufstetler of the 52nd, Harbison of the 15th and others AS PASSED A BILL TO BE ENTITLED AN ACT To amend Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to1 certification of private review agents, so as to provide for health insurers to implement and2 maintain a program that allows for the selective application of reductions in prior3 authorization requirements under certain circumstances; to provide for an annual filing; to4 provide for the promulgation of rules and regulations; to amend Chapter 24 of Title 33 and5 Chapter 18 of Title 45 of the Official Code of Georgia Annotate d, relating to insurance6 generally and employees' insurance and benefits plans, respectively, so as to require coverage7 for healthcare services for pediatric autoimmune neuropsychiatric disorders associated with8 streptococcal infection (PANDAS) and pediatric acute-onset neur opsychiatric syndrome9 (PANS) in accordance with nationally recognized clinical practice guidelines; to provide for10 definitions; to allow for deductibles; to prohibit special deductibles; to provide for rules and11 regulations; to provide for an effective date and applicability; to provide for related matters;12 to repeal conflicting laws; and for other purposes.13 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:14 S. B. 5 - 1 - 25 LC 52 0855S PART I15 SECTION 1-1.16 Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of17 private review agents, is amended by adding a new Code section to read as follows:18 "33-46-20.1.19 (a) Each insurer that utilizes prior authorization requirement s shall implement and20 maintain a program that allows for the selective application of reductions in prior21 authorization requirements based on the stratification of healthcare providers' performance22 and adherence to evidence based medicine. Such program shall p romote quality,23 affordable healthcare and reduce unnecessary administrative burdens for both the insurer24 and the healthcare provider.25 (b) Criteria for participation by healthcare providers and the healthcare services included26 in the program shall be at the discretion of the insurer; provided, however, that such insurer27 shall submit to the department a filing concerning such program. Such filing shall include28 a full narrative description of the program, the criteria for participation in the program, a29 list of the procedures and services subject to the program, the number of healthcare30 providers participating in the program, and any other information deemed necessary by the31 department.32 (c) No later than July 1, 2026, each insurer that utilizes prior authorization requirements33 shall make the filing provided for in subsection (b) of this Co de section, and such filing34 shall be submitted annually in a form and manner provided for b y rules and regulations35 promulgated by the Commissioner."36 S. B. 5 - 2 - 25 LC 52 0855S PART II37 SECTION 2-1.38 Chapter 24 of Title 33 of the Official Code of Georgia Annotate d, relating to insurance39 generally, is amended by adding a new Code section to read as follows:40 "33-24-59.34.41 (a) As used in this Code section, the term:42 (1) 'Health benefit policy' means any individual or group plan , policy, or contract for43 healthcare services issued, delivered, issued for delivery, or renewed in this state which44 provides major medical benefits, including those contracts exec uted by the State of45 Georgia on behalf of state employees under Article 1 of Chapter 18 of Title 45, by a46 healthcare corporation, health maintenance organization, preferred provider organization,47 accident and sickness insurer, fraternal benefit society, hospi tal service corporation,48 medical service corporation, or other insurer or similar entity . Such term shall not49 include any self-insured health benefit plan subject to the exc lusive jurisdiction of the50 federal Employee Retirement Income Security Act of 1974, 29 U.S .C. Section 1001,51 et seq.52 (2) 'Nationally recognized clinical practice guidelines' means evidence based clinical53 practice guidelines developed by independent organizations or m edical professional54 societies utilizing a transparent methodology and reporting structure and with a conflict55 of interest policy. Such guidelines establish standards of care informed by a systematic56 review of evidence and an assessment of the benefits and risks of alternative care options57 and include recommendations intended to optimize patient care.58 (3) 'Pediatric acute-onset neuropsychiatric syndrome' or 'PANS ' means a class of59 acute-onset obsessive compulsive or tic disorders or other behavioral changes presenting60 in children and adolescents that are not otherwise explained by another known neurologic61 or medical disorder.62 S. B. 5 - 3 - 25 LC 52 0855S (4) 'Pediatric autoimmune neuropsychiatric disorders associate d with streptococcal63 infections' or 'PANDAS' means a condition in which a streptococcal infection in a child64 or adolescent causes the abrupt onset of clinically significant obsessions, compulsions,65 tics, or other neuropsychiatric symptoms or behavioral changes, or a relapsing and66 remitting course of symptom severity.67 (b) All health benefit policies issued or renewed on or after July 1, 2025, shall include68 coverage for healthcare services for PANDAS or PANS for an individual covered under69 such policy as provided in this Code section.70 (c) Healthcare services for PANDAS or PANS for an individual c overed under a health71 benefit policy shall be covered for the purposes of diagnosis, treatment, appropriate72 management, or ongoing monitoring of a covered person's disorder when such services are73 supported by nationally recognized clinical practice guidelines.74 (d) The benefits in a health benefit policy as provided for in this Code section shall be75 subject to the same deductibles, coinsurance, copayment provisions, and other limitations76 established for all covered benefits within such health benefit policy. Special deductibles,77 coinsurance, copayment, and other limitations that are not gene rally applicable to other78 healthcare services covered by a health benefit policy shall not be imposed on coverage for79 healthcare services for PANDAS or PANS.80 (e) The Commissioner shall promulgate rules and regulations necessary to implement the81 provisions of this Code section."82 SECTION 2-2.83 Chapter 18 of Title 45 of the Official Code of Georgia Annotate d, relating to employees'84 insurance and benefit plans, is amended by adding a new Code section to read as follows:85 "45-18-4.2.86 (a) As used in this Code section, the term:87 S. B. 5 - 4 - 25 LC 52 0855S (1) 'Nationally recognized clinical practice guidelines' means evidence based clinical88 practice guidelines developed by independent organizations or m edical professional89 societies utilizing a transparent methodology and reporting structure and with a conflict90 of interest policy. Such guidelines establish standards of care informed by a systematic91 review of evidence and an assessment of the benefits and risks of alternative care options92 and include recommendations intended to optimize patient care.93 (2) 'Pediatric acute-onset neuropsychiatric syndrome' or 'PANS ' means a class of94 acute-onset obsessive compulsive or tic disorders or other behavioral changes presenting95 in children and adolescents that are not otherwise explained by another known neurologic96 or medical disorder.97 (3) 'Pediatric autoimmune neuropsychiatric disorders associate d with streptococcal98 infections' or 'PANDAS' means a condition in which a streptococcal infection in a child99 or adolescent causes the abrupt onset of clinically significant obsessions, compulsions,100 tics, or other neuropsychiatric symptoms or behavioral changes, or a relapsing and101 remitting course of symptom severity.102 (4) 'State health benefit plan' means the health insurance pla n or plans established103 pursuant to this article and Part 6 of Article 17 of Chapter 2 of Title 20 for state and104 public employees, dependents, and retirees.105 (b) Beginning January 1, 2026, the state health benefit plan s hall include coverage for106 healthcare services for PANDAS or PANS for an individual covered under such policy as107 provided in this Code section.108 (c) Healthcare services for PANDAS or PANS for an individual covered under the state109 health benefit plan shall be covered for the purposes of diagnosis, treatment, appropriate110 management, or ongoing monitoring of a covered person's disorder when such services are111 supported by nationally recognized clinical practice guidelines.112 (d) The benefits in the state health benefit plan as provided for in this Code section shall113 be subject to the same deductibles, coinsurance, copayment prov isions, and other114 S. B. 5 - 5 - 25 LC 52 0855S limitations established for all covered benefits within such pl an. Special deductibles,115 coinsurance, copayment, and other limitations that are not gene rally applicable to116 healthcare services covered by such plan shall not be imposed on coverage for healthcare117 services for PANDAS or PANS."118 PART III119 SECTION 3-1.120 This Act shall become effective on July 1, 2025, and shall apply to all policies or contracts121 issued, delivered, issued for delivery, or renewed in this state on or after such date.122 SECTION 3-2.123 All laws and parts of laws in conflict with this Act are repealed.124 S. B. 5 - 6 -