Healthcare

Nursing homes; periodic medical visits and resident assessments. Requires all nursing homes to notify the resident of a nursing home, the resident's family, and the Department of Health if a federally required physician visit does not take place. The bill also requires each nursing home to conduct a comprehensive assessment on an annual basis to determine each resident's needs and describe each resident's capability to perform daily life functions. Such assessments must be reviewed at least once every 92 days, and more frequently in the event of a significant change in the resident's physical or mental condition.

Health carriers; use of artificial intelligence; disclosures. Requires health carriers to disclose to the State Corporation Commission's Bureau of Insurance how artificial intelligence is used to manage claims coverage and to submit all information enabling decisions made by artificial intelligence to the Bureau upon request. The bill also requires health carriers to provide notice to enrollees and health care providers when artificial intelligence has been used to issue an adverse determination and to provide a clear and timely process for appeal of such determination.

Department of Behavioral Health and Developmental Services; Early Intervention Program for Infants and Toddlers with Disabilities; program extension. Directs the Department of Behavioral Health and Developmental Services to take all steps necessary to implement the federal extension option for the federal Early Intervention Program for Infants and Toddlers with Disabilities to allow children five years of age or younger to receive services through such program.

Health Care Decisions Act; patients incapable of making informed decisions; absence of next of kin. Authorizes, for purposes of the Health Care Decisions Act, the patient care consulting committee to make health care decisions for a patient incapable of making informed decisions when no next of kin is reasonably available.

Nursing facilities; related party rent disclosures; incentive payment reduction; penalty. Requires any nursing facility enrolled as a Medicaid provider that makes rent or lease payments to publicly disclose information related to the rent or lease payments, including whether payments are made to a related party, the nature of the related party, and the related party rent expense, as defined in the bill. The bill requires the Department of Medical Assistance Services to determine whether related party rent expenses exceed a fair rental value benchmark and if so, deduct a portion of any incentive payment owed to the nursing facility. A knowingly false attestation or disclosure is punishable as a Class 3 misdemeanor.

Virginia Birth-Related Neurological Injury Compensation Program; electronic filing; review of claims. Requires electronic filing of claims under the Virginia Birth-Related Neurological Injury Compensation Program. The bill requires such claims to include an uncondensed and uncompressed fetal heart rate monitoring record and prenatal records and increases from 10 days to 21 days the timeframe in which the Program is required to file a response to a claim. The bill also increases from $3,000 to $6,000 the amount paid to the medical school that assesses and prepares a report for a claim.

Health insurance; ensuring fairness in cost-sharing; pharmacy benefits managers; compensation and duties: civil penalty. Amends provisions related to rebates provided by carriers and health benefit plans to health plan enrollees by defining "defined cost-sharing," "pharmacy benefits management services," and "price protection rebates." The bill requires that an enrollee's defined cost-sharing for each prescription drug be calculated at the point of sale based on a price that is reduced by an amount equal to at least 80 percent of all rebates received or expected to be received in connection with the dispensing or administration of the prescription drug. The bill prohibits a pharmacy benefits manager from deriving income from pharmacy benefits management services provided to a carrier or health benefit plan except for income derived from a pharmacy benefits management fee. The bill requires the amount of any pharmacy benefits management fees to be set forth in the agreement between the pharmacy benefits manager and the carrier or health benefit plan and that such fee not be based on the acquisition cost or any other price metric of a drug; the amount of savings, rebates, or other fees charged, realized, or collected by or generated based on the activity of the pharmacy benefits manager; or the amount of premiums, deductibles, or other cost-sharing or fees charged, realized, or collected by the pharmacy benefits manager from enrollees or other persons on behalf of an enrollee. The bill requires a pharmacy benefits manager to annually certify to the State Corporation Commission that it has met certain requirements. The Commission is directed to impose a civil penalty not to exceed $1,000 per claim for a violation of these provisions. The bill establishes a pharmacy benefits manager duty, which includes the duties of care, good faith, and fair dealing, owed to any enrollee, provider, or health benefit plan that receives pharmacy benefits management services from the pharmacy benefits manager or that furnishes, covers, receives, or is administered a unit of a prescription drug for which the pharmacy benefits manager has provided pharmacy benefits management services. The bill requires the Commission to define by regulation the scope of such duty and provides for a private cause of action for any person aggrieved by the breach of such duty.

Pharmacy benefits managers; various requirements; report. Prohibits a pharmacy benefits manager from (i) reimbursing a pharmacy in an amount less than the national average drug acquisition cost for the prescription drug or pharmacy service at the time the drug is administered or dispensed, plus a professional dispensing fee; (ii) basing pharmacy reimbursement for prescription drugs on patient outcomes, scores, or metrics; (iii) imposing a point-of-sale or retroactive fee on a pharmacy, pharmacist, or covered individual; (iv) receiving deductibles or copayments; (v) redirecting any prescription drug claims submitted by a pharmacy to any third-party discount card program, cash discount program, or any other non-insurance adjudication platform; (vi) using policy agreements incorporation into a pharmacy agreement, to materially change, alter, or modify the pharmacy agreement, reimbursement rates, payment terms, or other financial obligations; (vii) prohibiting a pharmacy from providing an individual certain information; (viii) charging a pharmacy a fee related to participation in a pharmacy network; (ix) requiring multiple specialty pharmacy accreditations as a prerequisite for participation in a pharmacy network that dispenses specialty drugs; or (x) deriving any revenue from a pharmacist, pharmacy, or covered individual in connection with performing pharmacy benefits management services. The bill requires a pharmacy benefits manager to calculate a covered individual's out-of-pocket cost for a covered prescription drug based on the net price of the prescription drug after taking into account all retained rebates associated with the prescription drug. The bill adds certain information to be included in a report that pharmacy benefit managers are currently required to submit and requires such report to be filed quarterly rather than annually. The bill also requires the Commissioner of Insurance to annually prepare and submit a report to the Governor and the General Assembly based on the information submitted by pharmacy benefits managers. Additionally, the bill prohibits a carrier or its pharmacy benefits manager from imposing any payment or condition relating to the purchase of pharmaceutical benefits from any pharmacy that is more costly or more restrictive than that which would be imposed upon such person if the same pharmaceutical services were purchased from a mail order pharmacy provider.

Child abuse or neglect; prenatal use of a controlled substance or drug as prescribed. Clarifies that a pregnant woman's prenatal use of a controlled substance or drug as prescribed by such woman's health care provider shall not solely be a reason to suspect that a child is abused or neglected.