Bill
HB 5226
Michigan requires health plans to cover pediatric PANDAS and PANS treatments, including IVIG; applies to MI policies and some out-of-state plans, 90 days after enactment.
Status and procedural history
- Bill number: HB 5226 (amends 1956 PA 218 by adding sec. 3406pp).
- Filed: March 14, 2025. Read first time April 7, 2025; referred to Ways & Means.
- Electronically reproduced / introduced (reintroduction): November 6, 2025 (listed as introduced by Rep. Kelly Breen); referred to Committee on Insurance.
- Enacting provision: the act takes effect 90 days after enactment and applies to affected health insurance policies beginning 90 days after enactment.
Purpose and intent
- Require health insurers to provide coverage for the treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS). The bill explicitly cites coverage for intravenous immunoglobulin (IVIG) therapy and uses the phrase “including, but not limited to,” indicating coverage is required for IVIG and other medically necessary treatments for these conditions.
Key provisions
- Addition of Section 3406pp to the Michigan Insurance Code (1956 PA 218):
- Mandates that a health insurance policy delivered, issued for delivery, or renewed in Michigan must cover treatment for PANDAS and PANS.
- Specifically names IVIG therapy as a covered treatment example.
- Effective date: 90 days after the act is signed into law.
- Applicability: applies to policies delivered, executed, issued, amended, adjusted, or renewed in Michigan — and to out-of-state policies if they cover Michigan residents — beginning 90 days after enactment.
Scope and who is affected
- Primary effect: health insurance carriers that issue policies regulated under Michigan law (fully insured health plans issued in Michigan).
- Covered persons: pediatric patients diagnosed with PANDAS or PANS (the bill uses the term “pediatric”; the text does not further define age range).
- Potential limits/exclusions: the bill text does not specify benefit limits, medical necessity standards, prior authorization requirements, cost-sharing, or diagnostic criteria.
- Federally regulated plans (for example, many self‑insured employer plans governed by ERISA) may be outside state-law mandate scope; the bill text does not address federal preemption.
Potential impact and considerations
- Access: likely increases insurer-covered access to IVIG and other treatments for children with PANDAS/PANS.
- Cost: could increase insurer expenditures for covered treatments; insurers may adjust premiums or utilization management practices.
- Administrative: insurers might need to develop clinical criteria, prior authorization processes, or benefit language to implement the requirement.
- Implementation detail gaps: the bill does not define covered services comprehensively, set age or diagnostic criteria, or address cost-sharing, Medicaid/Medicare, or ERISA preemption — these issues could be clarified in regulation, guidance, or subsequent legislation.
Text reference
- Amends 1956 PA 218 (MCL 500.100–500.8302) by adding sec. 3406pp requiring coverage for treatment of PANDAS and PANS, including IVIG. Effective 90 days after enactment; applies to relevant policies beginning 90 days after enactment.
Compiled from official sources — confirm details with the bill’s official record.
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