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HB 5136

Human services: medical services; coverage for the prophylaxis, diagnosis, and treatment of certain pediatric autoimmune neuropsychiatric disorders; require. Amends 1939 PA 280 (MCL 400.1 - 400.119b) by adding sec. 109v.

2025-2026 Regular Session Introduced by Kelly Breen and 8 co-sponsors

Michigan Medicaid would cover diagnosis, treatment, and prevention of PANDAS/PANS for eligible children, with parity to other benefits and no lifetime limits.

bill electronically reproduced 10/23/2025
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Bill Summary · HB 5136

Bill Summary: HB 5136 (2025) — Medical assistance coverage for PANDAS/PANS

Bill number: HB 5136
Adds: Section 109v to 1939 PA 280 (The Social Welfare Act, MCL 400.1–400.119b)
Subject: Human services — medical assistance (Medicaid) coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS)
Introduced/Key dates: Filed March 13, 2025; committee activity and public hearing April 2025 (left pending); document electronically reproduced/introduced October 23, 2025; referred to House Committee on Insurance.

Purpose / Intent

Require the Michigan Department of Health and Human Services to provide coverage under the state medical assistance program (Medicaid) for prophylaxis, diagnosis, and treatment of PANDAS and PANS when prescribed or ordered by a physician or provider. The intent is to ensure these conditions and their treatments are covered comparably to other medical benefits.

Key provisions

  • Coverage required for prophylaxis, diagnosis, and treatment of PANDAS and PANS, including (but not limited to):
    • Antibiotics
    • Medications and behavioral therapies to manage neuropsychiatric symptoms
    • Immunomodulating medicines
    • Plasma exchange
    • Intravenous immunoglobulin (IVIG) therapy
  • Cost-sharing parity: benefits under this section cannot be subject to greater copayment, deductible, or coinsurance than other department benefits.
  • Prior authorization:
    • Required prior authorizations must be provided in a manner timely and appropriate to the severity of the condition.
    • Coverage must be provided under urgent-treatment standards when appropriate.
  • Non-discrimination in coverage:
    • The department may not deny or delay coverage because an individual previously received the same or similar treatment, was treated for the condition under a different diagnostic name (e.g., autoimmune encephalopathy), or was previously diagnosed/treated for another condition.
  • No lifetime limits:
    • Coverage for any therapy/treatment under this section must not be limited over an eligible individual’s lifetime (except as constrained by an individual’s Medicaid eligibility period).
  • Coding guidance:
    • For billing/diagnosis, PANDAS and PANS must be coded as autoimmune encephalopathy and as ICD‑10‑CM D89.89 (other specified disorders involving the immune mechanism not otherwise specified) unless a specific code is created by the AMA and CMS.
    • If a specific code is created, the conditions may be coded as autoimmune encephalopathy, PANDAS, or PANS.
    • If the AMA adopts ICD‑11‑CM, coding should follow 8E4A (paraneoplastic or autoimmune disorders of the central nervous system, brain, or spinal cord).
  • Effective date:
    • Applies to existing and future medical assistance coverage beginning 90 days after the bill is enacted.

Who is affected

  • Primary: Medicaid-eligible children diagnosed with PANDAS or PANS in Michigan and their families.
  • Secondary: Providers who diagnose/treat these conditions (pediatricians, psychiatrists, neurologists, immunologists), Medicaid program administrators, and billing/coding staff who will follow the specified diagnosis codes.
  • Fiscal impact: The bill mandates expanded Medicaid benefits; no cost estimates are included in the text.

Procedural status

  • Filed March 13, 2025; read and referred in April 2025 with committee hearing (left pending).
  • Document reproduced and introduced/referred to Committee on Insurance on October 23, 2025. Further committee and legislative action would be required for enactment.

Notes / Considerations

  • The bill establishes coverage standards but does not specify clinical eligibility criteria or prior authorization documentation requirements beyond timeliness and urgency standards.
  • No explicit appropriation or estimated fiscal impact is provided in the bill text.

Compiled from official sources — confirm details with the bill’s official record.

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