FISCAL NOTE
Date Requested: March 11, 2025
Time Requested: 09:20 AM |
| Agency: |
Public Employees Insurance Agency (PEIA) |
|---|
| CBD Number: |
Version: |
Bill Number: |
Resolution Number: |
| 1669 |
Introduced |
SB297 |
|
|---|
| CBD Subject: |
Insurance |
|---|
|
FUND(S):
PEIA Basic Insurance
Sources of Revenue:
Special Fund
Legislation creates:
Creates New Expense
Fiscal Note Summary
Effect this measure will have on costs and revenues of state government.
The purpose of this bill is to require Medicaid and insurance coverage of intravenous immunoglobulin therapy (IVIG) for pediatric autoimmune neuropsychiatric disorders associated with streptococcal (PANDAS) infections and pediatric acute onset neuropsychiatric syndrome (PANS) and other autoimmune encephalopathies with prior authorization once all other standard therapies have been exhausted.
The incidence and prevalence of PANDAS is not known at this time. Up to Date, a resource of scholarly articles and peer reviewed literature, states the incidence is rare and case studies identified only 10 cases among 30,000 throat cultures. Statistics quoted in the medical literature range from 1 in 200 children to 1 in 2000 children. This disorder is controversial as outlined in the Up to Date review of the disorder. The American Academy of Pediatrics consensus statement does recognize PANDAS/PANS and recommends consulting the PANDAS Physician’s Network Diagnostic and Treatment Guidelines. These guidelines are regularly updated based on the latest research and clinical insights.
IVIG does not have FDA approval for PANDAS/PANS. PEIA utilizes United Health Care medical policies which still consider IVIG treatment for PANDAS/PANS as experimental and investigational. In an Up to Date review of the disorder the authors quoted the following: “ Immune modulating therapy — Immune modulating therapies include glucocorticoids, plasma exchange, and intravenous immune globulin (IVIG) [77]. If PANDAS is an autoimmune disorder (and this remains controversial), immunomodulatory treatments might be beneficial, but they are as yet unproven and they carry risks. There are few well-designed trials of treatment for PANDAS [78]”.The medical research is still ongoing with PANDAS and the effectiveness of IVIG therapy has not been agreed upon.
PEIA currently covers antibiotics for group A streptococci infections, behavior and medical therapy for Obsessive-Compulsive Disorder and Tic Disorders, intravenous or oral steroids, plasmapheresis for PANDAS and autoimmune encephalitis, and IVIG for certain types of autoimmune encephalitis for these diagnoses.
The cost to PEIA for coverage of IVIG therapy for PANS/PANDAS is unknown since the dosage, number of treatments and the frequency of treatment has not been standardized. PEIA currently has 47,664 pediatric members. Using PEIA’s in state fee schedule, one dosage for an average ten-year-old child weighing 32kg is $17,625.60 based on a dosage of 2gram/kg. Using the 1 in 200 statistic would mean that 238 of those children would be diagnosed with PANDAS and possibly need treatment with IVIG. 1 in 2000 would be 24 children.
Depending on the rate of occurrence, a one-time dosage for 238 children would range from $1,785,227 to $7,740,400 depending on dosage used and brand. A one-time dosage for 24 children would be between $178,522 and $774,040. Current literature and studies range from one-time dosage of IVIG to monthly IVIG infusions. Cost will be increased if medication is used more than once or if the member is having infusions out of state and out of the PEIA fee schedule. For purposes of the fiscal note estimate, an average occurrence rate of 32.769 was used and the mid-point cost at this rate per the above dosages is $577,573.
Fiscal Note Detail
| Effect of Proposal |
Fiscal Year |
2025
Increase/Decrease
(use"-") |
2026
Increase/Decrease
(use"-") |
Fiscal Year
(Upon Full
Implementation) |
| 1. Estmated Total Cost |
0 |
0 |
577,573 |
| Personal Services |
0 |
0 |
0 |
| Current Expenses |
0 |
0 |
577,573 |
| Repairs and Alterations |
0 |
0 |
0 |
| Assets |
0 |
0 |
0 |
| Other |
0 |
0 |
0 |
| 2. Estimated Total Revenues |
0 |
0 |
0 |
Explanation of above estimates (including long-range effect):
The cost to PEIA for coverage of IVIG therapy for PANS/PANDAS is unknown since the dosage, number of treatments and the frequency of treatment has not been standardized. PEIA currently has 47,664 pediatric members. Using PEIA’s in state fee schedule, one dosage for an average ten-year-old child weighing 32kg is $17,625.60 based on a dosage of 2gram/kg. Using the 1 in 200 statistic would mean that 238 of those children would be diagnosed with PANDAS and possibly need treatment with IVIG. 1 in 2000 would be 24 children.
Depending on the rate of occurrence, a one-time dosage for 238 children would range from $1,785,227 to $7,740,400 depending on dosage used and brand. A one-time dosage for 24 children would be between $178,522 and $774,040. Current literature and studies range from one-time dosage of IVIG to monthly IVIG infusions. Cost will be increased if medication is used more than once or if the member is having infusions out of state and out of the PEIA fee schedule. For purposes of the fiscal note estimate, an average occurrence rate of 32.769 was used and the mid-point cost at this rate per the above dosages is $577,573.
Memorandum
Please identify any areas of vagueness, technical defects, reasons a bill would not have a fiscal impact, and/or any special issues not captured elsewhere on this form.
Person submitting Fiscal Note: Jason Haught
Email Address: jason.a.haught@wv.gov