HOUSE BILL NO. 5136

A bill to amend 1939 PA 280, entitled

"The social welfare act,"

(MCL 400.1 to 400.119b) by adding section 109v.

the people of the state of michigan enact:

Sec. 109v. (1) The department must provide coverage under the medical assistance program for the prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome that is prescribed or ordered by a physician or provider, including, but not limited to, antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and the use of intravenous immunoglobulin therapy.

(2) Benefits under the medical assistance program subject to this section must not be subject to any greater copayment, deductible, or coinsurance than any other benefits provided by the department.

(3) A required prior authorization for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome prophylaxis, diagnosis, or treatment must be provided in a timely manner that is appropriate for the severity of an eligible individual's condition. Coverage must be provided in a timely manner under standards for urgent treatments.

(4) The department shall not deny or delay coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or pediatric acute onset neuropsychiatric syndrome treatment or therapies under this section because the eligible individual previously received any treatment, including the same or similar treatment, for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, pediatric acute onset neuropsychiatric syndrome, or any other diagnosed condition or because the eligible individual was diagnosed with or received treatment for the eligible individual's condition under a different diagnostic name, including, but not limited to, autoimmune encephalopathy.

(5) Coverage under this section for any form of therapy or treatment that is prescribed or ordered by a physician or provider must not be limited over a lifetime of an eligible individual, except as limited by eligibility period.

(6) For billing and diagnosis purposes, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome must be coded as autoimmune encephalopathy and coded as D89.89 (other specified disorders involving the immune mechanism not otherwise specified) per the National Center for Health Statistics and ICD-10-CM unless the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. If the American Medical Association and the Centers for Medicare and Medicaid Services create and assign a specific code for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome may be coded as autoimmune encephalopathy, PANDAS, or PANS. If the American Medical Association adopts the ICD-11-CM, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome must be coded under 8E4A ? paraneoplastic or autoimmune disorders of the central nervous system, brain, or spinal cord.

(7) The amendatory act that added this section applies to existing medical assistance coverage and medical assistance coverage covering eligible individuals, beginning 90 days after the date this amendatory act is enacted into law.