Massachusetts Coverage for PANS/PANDAS

Frequently Asked Questions about Coverage for PANS/PANDAS

Massachusetts Chapter 260 of the Acts of 2020) created M.G.L. c. 175, §47NN; M.G.L. c. 176A, §8OO; M.G.L. c. 176B, §4OO; and M.G.L. c. 176G, §4GG to require insurance carriers providing fully insured health coverage to cover “treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acuteonset neuropsychiatric syndrome including, but not limited to, the use of intravenous immunoglobulin therapy…” (hereinafter referred to as “PANDAS and PANS”). 

The law applies to all fully insured plans issued under Massachusetts law by insurance companies, Blue Cross and Blue Shield of Massachusetts, and Health Maintenance Organizations (collectively referred to as “Insurance Carriers”).

Different Types of Health Plans

The law applies to all inured health plans as well as any plan insured through the Massachusetts Health Connector (e.g., all ConnectorCare Health Plans). 

The law does not extend to – and the Division of Insurance generally does not have authority over – the following types of health coverage: 

• Government programs such as Medicare or Medicaid 
• Insured plans issued in other states
  • Many MA residents work for an employer that is headquartered in another state and offers employee benefits through its headquarters.
  • Most out-of-state employer plans are subject to the state law where the coverage was issued. (Although this law does not apply to Blue Cross or HMOs, it does apply to Massachusetts residents, when an employer purchases coverage from an insurance company, such as UnitedHealthcare Insurance Company.)
• Self-funded employment-based health plans 
  • Many large employers self-fund employee health benefits – pay the benefits from their own resources - rather than buying insured plans from insurance carriers.
  • These plans are exempt from state insurance laws under federal ERISA statutes. 

Individuals may contact their employers’ human resource representative or their insurance Carrier to understand whether they are in an insured health benefit plan that is subject to the protections of the law. All Massachusetts-issued insured health plans should make it easy for covered individuals to verify their type of health coverage (e.g., fully insured).

Health Plans Offering Coverage through Networks of Providers

Most Massachusetts health carriers sponsor coverage through a network of health care providers and are expected to maintain an adequate network of providers to treat all covered benefits. Each managed care health plan is expected to maintain a list of providers that is readily available to consumers, providers and other parties about network providers available to treat PANS and PANDAs. 

As the Division noted in Bulletin 2021- 06 “[if] Carriers’ networks do not currently include adequate access to providers who can treat PANDAS and PANS, then Carriers are to cover medically necessary PANDAS and PANS services from out-of-network providers on an in-network basis until such time that an adequate network is developed.”

Managed Care Process

Many health plans use "utilization review" to decide whether certain services or access to certain providers are necessary according to their medical standards. If the plans decide that a service or provider is not medically necessary, the plan may deny or reduce payments. For some health plans, this medical necessity decision is made before treatment. For other health plans, the decision is made when the company gets a bill from the provider. 

If your insurance company decides that a service is not medically necessary, it must tell you in writing. This letter must tell you the reasons for its decision. It must also tell you that you have the right to file a grievance with the company. If you file a grievance and the company continues to deny coverage, you may appeal the decision to the Commonwealth of Massachusetts Office of Patient Protection. 

Internal Grievance Protections A managed care plan must allow you to file a grievance whenever the plan determines that a service is not medically necessary. You may file the grievance by calling, writing, or faxing the grievance to the company. The company must send you a notice within fifteen days acknowledging receipt of the grievance. They must resolve the grievance within 30 business days - unless you agree to an extension. They must send you a written resolution of the grievance within 30 business days. 

External Review Protections If you get a denial of your internal grievance, you have the right to file for an external review with the Office of Patient Protection (OPP). When the insurance company sends you the denial letter, itshould also send forms that you can submit to the OPP. The OPP will arrange for an independent external review within 45 days. You may also get these forms by calling the OPP.

Complaints

If you believe that any insured health plan is not complying with the requirements of Chapter 260, you should file a complaint with the Division of Insurance or by calling the Division of Insurance at [phone]