{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3418.22.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3418.22.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3418.22.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3418.22.html"}],"law_id":67690,"edition_id":1,"section_id":67690,"structure_id":14324,"section_number":"38.2-3418.22","catch_line":"Coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome","history":"2025, c. 8.","full_text":"A\n\nAs used in this section:\n\t\t\t“Pediatric acute-onset neuropsychiatric syndrome” or “PANS” means a clinically defined disorder characterized by the sudden onset of obsessive-compulsive symptoms (OCD) or eating restrictions, concomitant with acute behavioral deterioration in at least two designated domains. Comorbid PANS symptoms may include anxiety, sensory amplification or motor abnormalities, behavioral regression, deterioration in school performance, mood disorder, urinary symptoms, or sleep disturbances. PANS does not require a known trigger, although it is believed to be triggered by one or more pathogens.\n\t\t\t“Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections” or “PANDAS” means a subset of PANS that has five distinct criteria for diagnosis, including (i) abrupt “overnight” OCD or dramatic, disabling tics; (ii) a relapsing-remitting, episodic symptom course; (iii) young age at onset; (iv) presence of neurologic abnormalities; and (v) temporal association between symptom onset and Group A streptococcal infection. The five criteria of PANDAS are usually accompanied by similar comorbid symptoms as found in PANS.B\n\nNotwithstanding the provisions of § 38.2-3419 or subdivision A 1 of § 38.2-6506, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall provide coverage for the prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome. Such coverage shall include coverage for treatment using antimicrobials, medication, and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.C\n\nNo insurer, corporation, or organization providing coverage pursuant to this section shall (i) deny or delay the coverage required by this section because the enrollee previously received treatment, including the same or similar treatment, for these conditions or because the enrollee was diagnosed with or received treatment for his condition under a different diagnostic name, including autoimmune encephalopathy; (ii) limit coverage of immunomodulating therapies for the treatment of pediatric acute-onset neuropsychiatric syndrome and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections in a manner that is inconsistent with the treatment guidelines developed by a consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of such syndrome or disorders that are accessible for medical professionals and are based on evidence of positive patient outcomes; (iii) require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies for the treatment of pediatric acute-onset neuropsychiatric syndrome and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; or (iv) deny coverage for out-of-state treatment if the service is not available within the Commonwealth.D\n\nNothing in this section shall prevent an insurer, corporation, or organization from requesting treatment notes and the anticipated duration of treatment and outcomes.E\n\nNothing shall preclude the undertaking of usual and customary procedures, including prior authorization, to determine the appropriateness of, and medical necessity for, treatment of PANDAS and PANS under this section, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by such policy, contract, or plan.F\n\nThe coverage provided under this section shall not be more restrictive than or separate from coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors.G\n\nThe requirements of this section shall apply to all insurance policies, contracts, and plans delivered, issued for delivery, reissued, or extended in the Commonwealth on and after January 1, 2026, or at any time thereafter when any term of the policy, contract, or plan is changed or any premium adjustment is made.H\n\nThis section shall not apply to short-term travel, accident-only, or limited or specified disease policies or contracts, nor to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under federal governmental plans.","order_by":null,"text":{"0":{"id":245221,"text":"As used in this section:\n\t\t\t“Pediatric acute-onset neuropsychiatric syndrome” or “PANS” means a clinically defined disorder characterized by the sudden onset of obsessive-compulsive symptoms (OCD) or eating restrictions, concomitant with acute behavioral deterioration in at least two designated domains. Comorbid PANS symptoms may include anxiety, sensory amplification or motor abnormalities, behavioral regression, deterioration in school performance, mood disorder, urinary symptoms, or sleep disturbances. PANS does not require a known trigger, although it is believed to be triggered by one or more pathogens.\n\t\t\t“Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections” or “PANDAS” means a subset of PANS that has five distinct criteria for diagnosis, including (i) abrupt “overnight” OCD or dramatic, disabling tics; (ii) a relapsing-remitting, episodic symptom course; (iii) young age at onset; (iv) presence of neurologic abnormalities; and (v) temporal association between symptom onset and Group A streptococcal infection. The five criteria of PANDAS are usually accompanied by similar comorbid symptoms as found in PANS.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":245222,"text":"Notwithstanding the provisions of § 38.2-3419 or subdivision A 1 of § 38.2-6506, each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services shall provide coverage for the prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome. Such coverage shall include coverage for treatment using antimicrobials, medication, and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":245223,"text":"No insurer, corporation, or organization providing coverage pursuant to this section shall (i) deny or delay the coverage required by this section because the enrollee previously received treatment, including the same or similar treatment, for these conditions or because the enrollee was diagnosed with or received treatment for his condition under a different diagnostic name, including autoimmune encephalopathy; (ii) limit coverage of immunomodulating therapies for the treatment of pediatric acute-onset neuropsychiatric syndrome and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections in a manner that is inconsistent with the treatment guidelines developed by a consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of such syndrome or disorders that are accessible for medical professionals and are based on evidence of positive patient outcomes; (iii) require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies for the treatment of pediatric acute-onset neuropsychiatric syndrome and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; or (iv) deny coverage for out-of-state treatment if the service is not available within the Commonwealth.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":245224,"text":"Nothing in this section shall prevent an insurer, corporation, or organization from requesting treatment notes and the anticipated duration of treatment and outcomes.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":245225,"text":"Nothing shall preclude the undertaking of usual and customary procedures, including prior authorization, to determine the appropriateness of, and medical necessity for, treatment of PANDAS and PANS under this section, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by such policy, contract, or plan.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":245226,"text":"The coverage provided under this section shall not be more restrictive than or separate from coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":245227,"text":"The requirements of this section shall apply to all insurance policies, contracts, and plans delivered, issued for delivery, reissued, or extended in the Commonwealth on and after January 1, 2026, or at any time thereafter when any term of the policy, contract, or plan is changed or any premium adjustment is made.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"7":{"id":245228,"text":"This section shall not apply to short-term travel, accident-only, or limited or specified disease policies or contracts, nor to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under federal governmental plans.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G"}},"ancestry":[{"id":14324,"edition_id":1,"name":"Mandated Benefits","identifier":"2","label":"article","depth":3,"order_by":1,"parent_id":12993,"metadata":{},"date_created":"2026-06-26 03:47:45","date_modified":"2026-06-26 03:47:45","permalink":{"id":215143,"object_type":"structure","relational_id":14324,"identifier":"2","token":"38.2\/34\/2","url":"\/38.2\/34\/2\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12993,"edition_id":1,"name":"Provisions Relating to Accident and Sickness Insurance","identifier":"34","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:44:07","date_modified":"2026-06-26 03:44:07","permalink":{"id":214887,"object_type":"structure","relational_id":12993,"identifier":"34","token":"38.2\/34","url":"\/38.2\/34\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":87046,"structure_id":14324,"section_number":"38.2-3408","catch_line":"Policy providing for reimbursement for services that may be performed by certain practitioners other than physicians","url":"\/38.2-3408\/","token":"38.2\/34\/2\/38.2-3408","metadata":false},{"id":55621,"structure_id":14324,"section_number":"38.2-3409","catch_line":"Coverage of dependent children","url":"\/38.2-3409\/","token":"38.2\/34\/2\/38.2-3409","metadata":false},{"id":68501,"structure_id":14324,"section_number":"38.2-3410","catch_line":"Construction of policy generally; words \"physician\" and \"doctor\" to include dentist","url":"\/38.2-3410\/","token":"38.2\/34\/2\/38.2-3410","metadata":false},{"id":76551,"structure_id":14324,"section_number":"38.2-3411","catch_line":"Coverage of newborn children required","url":"\/38.2-3411\/","token":"38.2\/34\/2\/38.2-3411","metadata":false},{"id":71629,"structure_id":14324,"section_number":"38.2-3411.1","catch_line":"Coverage for child health supervision services","url":"\/38.2-3411.1\/","token":"38.2\/34\/2\/38.2-3411.1","metadata":false},{"id":70694,"structure_id":14324,"section_number":"38.2-3411.2","catch_line":"Coverage of adopted 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diabetes","url":"\/38.2-3418.10\/","token":"38.2\/34\/2\/38.2-3418.10","metadata":false},{"id":87414,"structure_id":14324,"section_number":"38.2-3418.11","catch_line":"Coverage for hospice care","url":"\/38.2-3418.11\/","token":"38.2\/34\/2\/38.2-3418.11","metadata":false},{"id":81464,"structure_id":14324,"section_number":"38.2-3418.12","catch_line":"Coverage for hospitalization and anesthesia for dental procedures","url":"\/38.2-3418.12\/","token":"38.2\/34\/2\/38.2-3418.12","metadata":false},{"id":82972,"structure_id":14324,"section_number":"38.2-3418.13","catch_line":"Coverage for the treatment of morbid obesity","url":"\/38.2-3418.13\/","token":"38.2\/34\/2\/38.2-3418.13","metadata":false},{"id":85731,"structure_id":14324,"section_number":"38.2-3418.14","catch_line":"Coverage for lymphedema","url":"\/38.2-3418.14\/","token":"38.2\/34\/2\/38.2-3418.14","metadata":false},{"id":71964,"structure_id":14324,"section_number":"38.2-3418.15","catch_line":"Coverage for prosthetic devices and components","url":"\/38.2-3418.15\/","token":"38.2\/34\/2\/38.2-3418.15","metadata":false},{"id":57543,"structure_id":14324,"section_number":"38.2-3418.15:1","catch_line":"Coverage for prosthetic devices and components","url":"\/38.2-3418.15_1\/","token":"38.2\/34\/2\/38.2-3418.15_1","metadata":false},{"id":61286,"structure_id":14324,"section_number":"38.2-3418.16","catch_line":"Coverage for telemedicine services","url":"\/38.2-3418.16\/","token":"38.2\/34\/2\/38.2-3418.16","metadata":false},{"id":81144,"structure_id":14324,"section_number":"38.2-3418.17","catch_line":"Coverage for autism spectrum disorder","url":"\/38.2-3418.17\/","token":"38.2\/34\/2\/38.2-3418.17","metadata":false},{"id":60567,"structure_id":14324,"section_number":"38.2-3418.18","catch_line":"Coverage for formula and enteral nutrition products as medicine","url":"\/38.2-3418.18\/","token":"38.2\/34\/2\/38.2-3418.18","metadata":false},{"id":79176,"structure_id":14324,"section_number":"38.2-3418.19","catch_line":"Coverage for organ, eye or tissue transplant","url":"\/38.2-3418.19\/","token":"38.2\/34\/2\/38.2-3418.19","metadata":false},{"id":69963,"structure_id":14324,"section_number":"38.2-3418.1:1","catch_line":"Repealed","url":"\/38.2-3418.1_1\/","token":"38.2\/34\/2\/38.2-3418.1_1","metadata":false},{"id":72277,"structure_id":14324,"section_number":"38.2-3418.1:2","catch_line":"Coverage for pap smears","url":"\/38.2-3418.1_2\/","token":"38.2\/34\/2\/38.2-3418.1_2","metadata":false},{"id":64216,"structure_id":14324,"section_number":"38.2-3418.1:3","catch_line":"Cost sharing for breast examinations","url":"\/38.2-3418.1_3\/","token":"38.2\/34\/2\/38.2-3418.1_3","metadata":false},{"id":80233,"structure_id":14324,"section_number":"38.2-3418.2","catch_line":"Coverage of procedures involving bones and 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This law was first created in 2025. The record of its establishment is cataloged in chapter 8<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year.<\/p>","references":[{"id":67952,"section_number":"38.2-4319","catch_line":"Statutory construction and relationship to other laws","order_by":null,"url":"\/38.2-4319\/"}],"refers_to":[{"id":66144,"section_number":"38.2-3419","catch_line":"Additional mandated coverage made optional to group policy or contract holder","order_by":null,"url":"\/38.2-3419\/"},{"id":81163,"section_number":"38.2-6506","catch_line":"Certification of health benefit plans as qualified health plans","order_by":null,"url":"\/38.2-6506\/"}],"permalink":{"id":215289,"object_type":"law","relational_id":67690,"identifier":"38.2-3418.22","token":"38.2\/34\/2\/38.2-3418.22","url":"\/38.2-3418.22\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3418.22\/","token":"38.2\/34\/2\/38.2-3418.22","dublin_core":{"Title":"Coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3418.22","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> As used in this section:\n\t\t\t“Pediatric acute-onset neuropsychiatric syndrome<\/span>” or “PANS<\/span>” means a clinically defined disorder characterized by the sudden onset of obsessive-compulsive symptoms (OCD) or eating restrictions, concomitant with acute behavioral deterioration in at least two designated domains. Comorbid PANS<\/span> symptoms may include anxiety, sensory amplification or motor abnormalities, behavioral regression, deterioration in school performance, mood disorder, urinary symptoms, or sleep disturbances. PANS<\/span> does not require a known trigger, although it is believed to be triggered by one or more pathogens.\n\t\t\t“Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections<\/span>” or “PANDAS<\/span>” means a subset of PANS<\/span> that has five distinct criteria for diagnosis, including (i) abrupt “overnight<\/span>” OCD or dramatic, disabling tics; (ii) a relapsing-remitting, episodic symptom course; (iii) young age at onset; (iv) presence of neurologic abnormalities; and (v) temporal association between symptom onset and Group A streptococcal infection. The five criteria of PANDAS<\/span> are usually accompanied by similar comorbid symptoms as found in PANS<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> Notwithstanding the provisions of § 38.2-3419<\/a> or subdivision A 1 of § 38.2-6506<\/a>, each insurer<\/span> proposing to issue<\/span> individual or group accident and sickness insurance policies<\/span> providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts<\/span>; and each health maintenance organization providing a health care plan for health care services shall provide coverage for the prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections<\/span> and pediatric acute-onset neuropsychiatric syndrome<\/span>. Such coverage shall include coverage for treatment using antimicrobials, medication, and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> No insurer<\/span>, corporation, or organization providing coverage pursuant to this section shall (i) deny or delay the coverage required by this section because the enrollee previously received treatment, including the same or similar treatment, for these conditions or because the enrollee was diagnosed with or received treatment for his condition under a different diagnostic name, including autoimmune encephalopathy; (ii) limit coverage of immunomodulating therapies for the treatment of pediatric acute-onset neuropsychiatric syndrome<\/span> and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections<\/span> in a manner that is inconsistent with the treatment guidelines developed by a consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of such syndrome or disorders that are accessible for medical professionals and are based on evidence<\/span> of positive patient outcomes; (iii) require a trial<\/span> of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies for the treatment of pediatric acute-onset neuropsychiatric syndrome<\/span> and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections<\/span>; or (iv) deny coverage for out-of-state<\/span> treatment if the service is not available within the Commonwealth. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Nothing in this section shall prevent an insurer<\/span>, corporation, or organization from requesting treatment notes and the anticipated duration of treatment and outcomes. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> Nothing shall preclude the undertaking of usual and customary procedures, including prior authorization, to determine the appropriateness of, and medical necessity for, treatment of PANDAS<\/span> and PANS<\/span> under this section, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by such policy, contract<\/span>, or plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The coverage provided under this section shall not be more restrictive than or separate from coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> The requirements of this section shall apply to all insurance policies<\/span>, contracts<\/span>, and plans delivered, issued for delivery, reissued, or extended in the Commonwealth on and after January 1, 2026, or at any time thereafter when any term of the policy, contract<\/span>, or plan is changed or any premium adjustment is made. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> This section shall not apply to short-term travel, accident-only, or limited or specified disease policies or contracts<\/span>, nor to policies or contracts<\/span> designed for issuance to persons<\/span> eligible for coverage under Title XVIII of the Social Security Act, known as Medicare<\/span>, or any other similar coverage under federal governmental plans. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nCOVERAGE FOR PEDIATRIC AUTOIMMUNE NEUROPSYCHIATRIC DISORDERS ASSOCIATED WITH\nSTREPTOCOCCAL INFECTIONS AND PEDIATRIC ACUTE-ONSET NEUROPSYCHIATRIC SYNDROME (\u00a7\n38.2-3418.22)\n\nA. As used in this section:\n\t\t\t“Pediatric acute-onset neuropsychiatric syndrome” or\n“PANS” means a clinically defined disorder characterized by the\nsudden onset of obsessive-compulsive symptoms (OCD) or eating restrictions,\nconcomitant with acute behavioral deterioration in at least two designated\ndomains. Comorbid PANS symptoms may include anxiety, sensory amplification or\nmotor abnormalities, behavioral regression, deterioration in school performance,\nmood disorder, urinary symptoms, or sleep disturbances. PANS does not require a\nknown trigger, although it is believed to be triggered by one or more pathogens.\n\t\t\t“Pediatric autoimmune neuropsychiatric disorders associated with\nstreptococcal infections” or “PANDAS” means a subset of PANS\nthat has five distinct criteria for diagnosis, including (i) abrupt\n“overnight” OCD or dramatic, disabling tics; (ii) a\nrelapsing-remitting, episodic symptom course; (iii) young age at onset; (iv)\npresence of neurologic abnormalities; and (v) temporal association between\nsymptom onset and Group A streptococcal infection. The five criteria of PANDAS\nare usually accompanied by similar comorbid symptoms as found in PANS.\n\nB. Notwithstanding the provisions of § 38.2-3419 or subdivision A 1 of\n§ 38.2-6506, each insurer proposing to issue individual or group accident\nand sickness insurance policies providing hospital, medical and surgical, or\nmajor medical coverage on an expense-incurred basis; each corporation providing\nindividual or group accident and sickness subscription contracts; and each\nhealth maintenance organization providing a health care plan for health care\nservices shall provide coverage for the prophylaxis, diagnosis, and treatment of\npediatric autoimmune neuropsychiatric disorders associated with streptococcal\ninfections and pediatric acute-onset neuropsychiatric syndrome. Such coverage\nshall include coverage for treatment using antimicrobials, medication, and\nbehavioral therapies to manage neuropsychiatric symptoms, immunomodulating\nmedicines, plasma exchange, and intravenous immunoglobulin therapy.\n\nC. No insurer, corporation, or organization providing coverage pursuant to this\nsection shall (i) deny or delay the coverage required by this section because\nthe enrollee previously received treatment, including the same or similar\ntreatment, for these conditions or because the enrollee was diagnosed with or\nreceived treatment for his condition under a different diagnostic name,\nincluding autoimmune encephalopathy; (ii) limit coverage of immunomodulating\ntherapies for the treatment of pediatric acute-onset neuropsychiatric syndrome\nand pediatric autoimmune neuropsychiatric disorders associated with\nstreptococcal infections in a manner that is inconsistent with the treatment\nguidelines developed by a consortium convened for the purposes of researching,\nidentifying, and publishing best practice standards for diagnosis and treatment\nof such syndrome or disorders that are accessible for medical professionals and\nare based on evidence of positive patient outcomes; (iii) require a trial of\ntherapies that treat only neuropsychiatric symptoms before authorizing coverage\nof immunomodulating therapies for the treatment of pediatric acute-onset\nneuropsychiatric syndrome and pediatric autoimmune neuropsychiatric disorders\nassociated with streptococcal infections; or (iv) deny coverage for out-of-state\ntreatment if the service is not available within the Commonwealth.\n\nD. Nothing in this section shall prevent an insurer, corporation, or\norganization from requesting treatment notes and the anticipated duration of\ntreatment and outcomes.\n\nE. Nothing shall preclude the undertaking of usual and customary procedures,\nincluding prior authorization, to determine the appropriateness of, and medical\nnecessity for, treatment of PANDAS and PANS under this section, provided that\nall such appropriateness and medical necessity determinations are made in the\nsame manner as those determinations are made for the treatment of any other\nillness, condition, or disorder covered by such policy, contract, or plan.\n\nF. The coverage provided under this section shall not be more restrictive than\nor separate from coverage provided for any other illness, condition, or disorder\nfor purposes of determining deductibles, benefit year or lifetime durational\nlimits, benefit year or lifetime dollar limits, lifetime episodes or treatment\nlimits, copayment and coinsurance factors, and benefit year maximum for\ndeductibles and copayments and coinsurance factors.\n\nG. The requirements of this section shall apply to all insurance policies,\ncontracts, and plans delivered, issued for delivery, reissued, or extended in\nthe Commonwealth on and after January 1, 2026, or at any time thereafter when\nany term of the policy, contract, or plan is changed or any premium adjustment\nis made.\n\nH. This section shall not apply to short-term travel, accident-only, or limited\nor specified disease policies or contracts, nor to policies or contracts\ndesigned for issuance to persons eligible for coverage under Title XVIII of the\nSocial Security Act, known as Medicare, or any other similar coverage under\nfederal governmental plans.\n\nHISTORY: 2025, c. 8.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}