33-24-59.36. Required coverage for healthcare services for PANDAS or PANS.

As used in this Code section, the term:#

1. (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. (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. (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. (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.#

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.#

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.#

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.#

The Commissioner shall promulgate rules and regulations necessary to implement the provisions of this Code section.#