Department of Medical Assistance Services; enhanced oversight of services facilitators. Directs the Department of Medical Assistance Services to enhance oversight of Medicaid services facilitation for consumer directed services, including incorporation of such services into the statewide Fiscal Employer Agent contract and development of a contract monitoring and oversight plan.
Firefighters Cancer Screening Grant Program and Fund established. Creates the Firefighters Cancer Screening Grant Program and Fund to award grants to localities for costs incurred in providing certain cancer detection tests to firefighters. The bill provides that in any year that the amount of funds in the Firefighters Cancer Screening Fund reduces to zero and the Fund does not receive a separate appropriation, the Grant Program and Fund shall expire.
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.
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.
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.
Pharmacy freedom of choice; specialty pharmacy benefits. Provides that in no event shall any person receiving a covered specialty pharmacy benefit from a nonpreferred or nonparticipating provider, regardless of whether it has submitted a reimbursement agreement, be responsible for amounts that may be charged by the nonpreferred or nonparticipating provider in excess of the copayment and the insurer's reimbursement applicable to all of its preferred or participating pharmacy providers.
State pharmacy benefits manager; contractual provisions; report. Requires the Department of Medical Assistance Services' contract with the state pharmacy benefits manager to (i) require that that ingredient-cost reimbursement is based on the national average drug acquisition cost, or if unavailable, the wholesale acquisition cost minus a discount set by the Department, plus a professional dispensing fee, determined by the Department; (ii) require real-time or near real-time transparency in drug costs, rebates collected and paid, dispensing fees paid, administrative fees, and all other charges, fees, costs, and holdbacks, claim denials appeals, and network participation; (iii) prohibit the state pharmacy benefits manager from steering Medicaid recipients to affiliated pharmacies through differential cost-sharing, restrictive network design, or the mandatory use of a mail order pharmacy provider; (iv) require the state pharmacy benefits manager to (a) meet network adequacy standards established by the Department; (b) allow any willing pharmacy to participate in the pharmacy network; (c) verify that all contracted pharmacies are actively accepting Medicaid recipients; (d) submit annual reports containing certain information; (e) disclose to the Department pricing and maximum acquisition cost methodologies; and (f) allow invoice-based or national average drug acquisition cost-based appeals and require an adjustment of rates network-wide when an appeal is upheld; and (v) include enforcement mechanisms and monetary penalties for noncompliance. Additionally, the bill requires Department to annually calculate the savings generated by the use of the state pharmacy benefits manager and to annually increase its dispensing fee by the amount of such savings. The bill requires the Department to annually (1) publish and make available on its website its annual and total savings achieved, the annual and total amount applied to dispensing fees increases, and the updated dispensing fees and (2) report to the General Assembly on the state pharmacy benefits manager's compliance, national average drug acquisition cost compliance, pharmacy reimbursement trends, network adequacy compliance, and dispensing fee sufficiency.
Constitutional amendment (voter referendum); fundamental right to reproductive freedom. Provides for a referendum at the November 3, 2026, election to approve or reject an amendment to the Constitution of Virginia relating to the right to make one's own decisions related to reproductive health care, including access to abortion. The amendment protects patients and their doctors and nurses from being punished for making such decisions. The amendment allows the state to place restrictions on access to abortion during the third trimester of pregnancy except when the patient's life or physical or mental health is at risk or the pregnancy cannot survive. This bill is identical to HB 781.
