SB 5: Private Review Agents; health insurers to implement and maintain a program that allows for the selective application of reductions in prior authorization requirements; provide

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 to certification of private review agents, so as to provide for health insurers to implement and maintain a program that allows for the selective application of reductions in prior authorization requirements under certain circumstances; to provide for an annual filing; to provide for the promulgation of rules and regulations; to amend Chapter 24 of Title 33 and Chapter 18 of Title 45 of the Official Code of Georgia Annotated, relating to insurance generally and employees' insurance and benefits plans, respectively, so as to require coverage for healthcare services for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome

(PANS) in accordance with nationally recognized clinical practice guidelines; to provide for definitions; to allow for deductibles; to prohibit special deductibles; to provide for rules and regulations; to provide for an effective date and applicability; to provide for related matters; to repeal conflicting laws; and for other purposes.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:

PART I

SECTION 1-1.

Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of private review agents, is amended by adding a new Code section to read as follows:

"33-46-20.1.

(a) Each insurer that utilizes prior authorization requirements shall implement and maintain a program that allows for the selective application of reductions in prior authorization requirements based on the stratification of healthcare providers' performance and adherence to evidence based medicine. Such program shall promote quality, affordable healthcare and reduce unnecessary administrative burdens for both the insurer and the healthcare provider.

(b) Criteria for participation by healthcare providers and the healthcare services included in the program shall be at the discretion of the insurer; provided, however, that such insurer shall submit to the department a filing concerning such program. Such filing shall include a full narrative description of the program, the criteria for participation in the program, a list of the procedures and services subject to the program, the number of healthcare providers participating in the program, and any other information deemed necessary by the department.

(c) No later than July 1, 2026, each insurer that utilizes prior authorization requirements shall make the filing provided for in subsection (b) of this Code section, and such filing shall be submitted annually in a form and manner provided for by rules and regulations promulgated by the Commissioner."

PART II

SECTION 2-1.

Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to insurance generally, is amended by adding a new Code section to read as follows:

"33-24-59.34.

(a) As used in this Code section, the term:

(1) 'Health benefit policy' means any individual or group plan, policy, or contract for healthcare services issued, delivered, issued for delivery, or renewed in this state which provides major medical benefits, including those contracts executed by the State of Georgia on behalf of state employees under Article 1 of Chapter 18 of Title 45, by a healthcare corporation, health maintenance organization, preferred provider organization, accident and sickness insurer, fraternal benefit society, hospital service corporation, medical service corporation, or other insurer or similar entity. Such term shall not include any self-insured health benefit plan subject to the exclusive jurisdiction of the federal Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et seq.

(2) 'Nationally recognized clinical practice guidelines' means evidence based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. Such guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.

(3) 'Pediatric acute-onset neuropsychiatric syndrome' or 'PANS' means a class of acute-onset obsessive compulsive or tic disorders or other behavioral changes presenting in children and adolescents that are not otherwise explained by another known neurologic or medical disorder.

(4) 'Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections' or 'PANDAS' means a condition in which a streptococcal infection in a child or adolescent causes the abrupt onset of clinically significant obsessions, compulsions, tics, or other neuropsychiatric symptoms or behavioral changes, or a relapsing and remitting course of symptom severity.

(b) All health benefit policies issued or renewed on or after July 1, 2025, shall include coverage for healthcare services for PANDAS or PANS for an individual covered under such policy as provided in this Code section.

(c) Healthcare services for PANDAS or PANS for an individual covered under a health benefit policy shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a covered person's disorder when such services are supported by nationally recognized clinical practice guidelines.

(d) The benefits in a health benefit policy as provided for in this Code section shall be subject to the same deductibles, coinsurance, copayment provisions, and other limitations established for all covered benefits within such health benefit policy. Special deductibles, coinsurance, copayment, and other limitations that are not generally applicable to other healthcare services covered by a health benefit policy shall not be imposed on coverage for healthcare services for PANDAS or PANS.

(e) The Commissioner shall promulgate rules and regulations necessary to implement the provisions of this Code section."

SECTION 2-2.

Chapter 18 of Title 45 of the Official Code of Georgia Annotated, relating to employees' insurance and benefit plans, is amended by adding a new Code section to read as follows:

"45-18-4.2.

(a) As used in this Code section, the term:

(1) 'Nationally recognized clinical practice guidelines' means evidence based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. Such guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care.

(2) 'Pediatric acute-onset neuropsychiatric syndrome' or 'PANS' means a class of acute-onset obsessive compulsive or tic disorders or other behavioral changes presenting in children and adolescents that are not otherwise explained by another known neurologic or medical disorder.

(3) 'Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections' or 'PANDAS' means a condition in which a streptococcal infection in a child or adolescent causes the abrupt onset of clinically significant obsessions, compulsions, tics, or other neuropsychiatric symptoms or behavioral changes, or a relapsing and remitting course of symptom severity.

(4) 'State health benefit plan' means the health insurance plan or plans established pursuant to this article and Part 6 of Article 17 of Chapter 2 of Title 20 for state and public employees, dependents, and retirees.

(b) Beginning January 1, 2026, the state health benefit plan shall include coverage for healthcare services for PANDAS or PANS for an individual covered under such policy as provided in this Code section.

(c) Healthcare services for PANDAS or PANS for an individual covered under the state health benefit plan shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a covered person's disorder when such services are supported by nationally recognized clinical practice guidelines.

(d) The benefits in the state health benefit plan as provided for in this Code section shall be subject to the same deductibles, coinsurance, copayment provisions, and other limitations established for all covered benefits within such plan. Special deductibles, coinsurance, copayment, and other limitations that are not generally applicable to healthcare services covered by such plan shall not be imposed on coverage for healthcare services for PANDAS or PANS."

PART III

SECTION 3-1.

This Act shall become effective on July 1, 2025, and shall apply to all policies or contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.

SECTION 3-2.

All laws and parts of laws in conflict with this Act are repealed.