A. As used in this section: “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. “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. 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.
C. 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.
D. Nothing in this section shall prevent an insurer, corporation, or organization from requesting treatment notes and the anticipated duration of treatment and outcomes.
E. 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.
F. 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.
G. 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.
H. 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.