Illinois Statutes Chapter 215. Insurance § 5/356z.25. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome

§ 356z.25. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. A group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed after July 18, 2017 (the effective date of Public Act 100-24) shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome, including, but not limited to, the use of intravenous immunoglobulin therapy.

No group or individual policy of accident and health insurance or managed care plan shall deny or delay coverage for medically necessary treatment under this Section solely because the insured, enrollee, or beneficiary previously received any treatment, including the same or similar treatment, for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections or pediatric acute onset neuropsychiatric syndrome, or because the insured, enrollee, or beneficiary has been diagnosed with or receives treatment for an otherwise diagnosed condition.

For the purposes of this Section, coverage of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome shall adhere to the treatment recommendations developed by a medical professional consortium convened for the purposes of researching, identifying, and publishing best practice standards for diagnosis and treatment of such disorders or syndrome that are accessible for medical professionals and are based on evidence of positive patient outcomes. Coverage for any form of medically necessary treatment shall not be limited over a lifetime of an insured, enrollee, or beneficiary, unless the patient is no longer benefiting from the treatment, or by policy period. Nothing in this Section prevents insurers from requesting treatment notes and anticipated duration of treatment and outcomes.

For billing and diagnosis purposes, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome shall be coded as autoimmune encephalitis until 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. Thereafter, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome may be coded as autoimmune encephalitis, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or pediatric acute onset neuropsychiatric syndrome.

If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome outlined in this Section, then the requirement that an insurer cover pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.