Healthcare

Administrative Process Act; exemptions; limitations; appeals of case decisions regarding benefits sought. Specifies that the Administrative Process Act applies to case decisions regarding the grant or denial, including determinations of eligibility and approved levels of service, of Temporary Assistance for Needy Families, Medicaid, Supplemental Nutrition Assistance Program benefits, general relief, auxiliary grants, or state-local hospitalization. The bill also removes provisions limiting review of case decisions to ascertaining whether there was evidence in the agency record to support the case decision of the agency.

Health insurance; treatment of cancer and certain diseases; coverage of certain medications. Requires an insurer, corporation providing preferred provider subscription contracts, or health maintenance organization that provides coverage for drugs approved by the Food and Drug Administration and prescribed for the treatment of cancer or diseases of the blood to allow, at the patient's direction, (i) provider-administered drugs for such treatment to be dispensed by an in-network treating provider consistent with a provider agreement; (ii) provider-administered drugs for such treatment to be dispensed by an in-network treating provider when there is a documented delay of at least three days in the delivery of a medication from the designated specialty pharmacy; and (iii) self-administered drugs for such treatment to be sent to the pharmacy of the patient's choosing.

Fees for vehicles designed and used for transportation of passengers; funds returned to a locality; permitted uses. Expands the permitted use of funds returned to a locality from certain vehicle fees to include the purchase or maintenance of necessary equipment, supplies, facilities, and vehicles permitted by the Office of Emergency Medical Services and other operating expenses deemed necessary by the locality to ensure the provision of emergency medical services in such locality by nonprofit emergency medical services agencies. Under current law, such funds may be used for the purchase of necessary equipment and supplies for use in the locality for emergency medical services provided by nonprofit emergency medical services agencies.

Health insurance; large group policies; coverage for scalp treatment during cancer chemotherapy treatment. Requires health insurance carriers offering policies in the large group market to provide coverage for scalp cooling systems for the preservation of hair during cancer chemotherapy treatment. Provisions of the bill apply to health insurance policies, contracts, and plans delivered, issued for delivery, or renewed in the large group market in the Commonwealth on and after January 1, 2027.

Health insurance; State Plan for Medical Assistance; coverage for prosthetic and custom orthotic devices and components; reports. Amends provisions related to health insurance coverage for prosthetic devices and components to include custom orthotic devices and components. Under the bill, such coverage does not include repair and replacement due to theft or loss and may include more than one prosthetic or custom orthotic device when medically necessary, as determined by an enrollee's provider. The bill prohibits an insurer from denying coverage for a prosthetic or custom orthotic device for an individual with limb loss, limb absence, or limb impairment that would otherwise be covered for a nondisabled individual seeking medical or surgical intervention. The bill requires health plans that provide such coverage to include language describing an enrollee's rights related to coverage for prosthetic and custom orthotic devices and provide a written explanation of any claim denials. The bill also directs the Department of Medical Assistance Services to seek the necessary permissions from the Centers for Medicare and Medicaid Services to provide payment of medical assistance for prosthetic and custom orthotic devices, subject to the same requirements as insurers. Such payment is conditional on the Department obtaining all necessary approvals and federal financial participation. The bill sunsets on July 1, 2027, if such approval and federal financial participation is not obtained. The bill directs the health insurance carriers, the Department of Medical Assistance Services, and any managed care plan administering Medicaid benefits in the Commonwealth to submit reports to the Health Insurance Reform Commission regarding implementation of the provisions of the bill during plan years 2027 and 2028.

Health insurance; coverage for standard fertility preservation procedures. Requires health insurance carriers to provide coverage for standard fertility preservation procedures. The bill provides that "standard fertility preservation procedures" means procedures to preserve fertility that are consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine or the American Society of Clinical Oncology for a person who has cancer, sickle cell disease, or other medical condition or is expected to undergo medication therapy, surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment to fertility.

Supervised billing; Medicaid and health insurance plans. Requires the Department of Medical Assistance Services to permit a qualified licensed provider to bill for clinical services provided by a qualified non-licensed provider under the supervision of the qualified licensed provider and requires health insurance carriers to provide coverage for mental health services or substance use services provided by a qualified non-licensed provider under the supervision of a qualified licensed provider when such services would be covered if provided by a qualified licensed provider. Additionally, the bill reduces the time limit for a retroactive denial by a health insurance carrier from 12 months to 180 days.

Insurance; Fire Programs Fund; purposes; Virginia At Risk Fire Grant Program established. Increases the assessment on certain insurance companies from one percent to 1.5 percent. The bill provides that the portion of the Fire Programs Fund allocated to localities may be used for the additional purposes of (i) constructing, improving, or expanding fire station facilities; (ii) providing mental health resources for fire personnel; or (iii) hiring additional fire personnel and funding recruitment and retention programs. The bill also prohibits such funds from being used, except as provided, for the purposes of investments, operating expenses, debt repayment, taxes, or fees. The bill also establishes the Virginia At Risk Fire Grant Program, to be funded by 0.25 percent of the assessments on insurance companies, for the purposes of providing assistance to localities with fire departments that are determined to be most at risk of being unable to provide fire suppression or rescue activities or maintain compliance with relevant laws and regulations.

Workers' compensation; presumption for certain cancers; sheriffs and deputy sheriffs. Expands the workers' compensation presumption of compensability for certain cancers causing the death or disability of certain employees who have completed five years of service in their position to include sheriffs or deputy sheriffs.

Health insurance; coverage for doula care services. Requires health insurers, corporations providing health care subscription contracts, and health maintenance organizations whose policy, contract, or plan includes coverage for obstetrical services to provide coverage for doula care services provided by a state-certified doula. The bill requires such coverage to include coverage for at least eight visits during the antepartum or postpartum period and support during labor and delivery. The bill provides that health insurance carriers are (i) not required to pay for duplicate services actually rendered by both a state-certified doula and another health care provider and (ii) prohibited from requiring supervision, signature, or referral by any other health care provider as a condition of reimbursement for doula care services, except when those requirements are also applicable to other categories of health care providers.