School boards; courses of instruction; high school courses or dual enrollment programs for certification as a certified nurse aide, emergency medical technician, or firefighter; establishment permitted; requirements. Permits any school board to provide to high school students, either on school premises or through a dual enrollment program or other partnership with a comprehensive community college, courses of instruction that prepare students for and lead to (i) certification as a certified nurse aide, provided that such course is approved by and meets the requirements of the Board of Nursing and is taught by a qualified individual, consistent with the requirements of the Board of Nursing; (ii) certification as an emergency medical technician, provided that such course is consistent with the requirements established by the Office of Emergency Medical Services and taught by an emergency medical technician instructor who meets the requirements set forth in the bill; or (iii) firefighting level 1 certification, as defined by the bill, provided that such course is consistent with the National Fire Protection Association 1001, level one, firefighter standards as administered by the Department of Fire Programs and taught by an individual qualified to provided such instruction. The bill also requires any school board that provides any such course of instruction on school premises to high school students to ensure that any individual employed, contracted, or permitted to volunteer to provide instruction in such course meets the requirements set forth in applicable law relating to data on convictions for certain crimes and child abuse and neglect, fingerprinting, and criminal history records checks.
Certificate of public need; exception; maternal and perinatal health services. Creates an exception to certificate of public need requirements for any project or action related to maternal and perinatal health services. The bill also removes neonatal intensive care from the definition of tertiary care for purposes of determining health planning regions.
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; prior authorization requests reviewed by physician. Requires a provider contract between a health insurance carrier and a provider to contain provisions requiring (i) any decision to deny a prior authorization request for drug benefits or health care services is made by a licensed physician who is (a) an expert in the treatment of the enrollee's medical condition that is the subject of the prior authorization request and (b) knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the enrollee and (ii) if the carrier is questioning the medical necessity of the request, the carrier will provide the enrollee's physician an opportunity to discuss the medical necessity of the health care service with the physician who will be responsible for determining authorization of the health care service or drug benefit under review.
Health insurance; prior authorization for health care services. Decreases from 72 hours to 24 hours and from seven days to five days the time by which a health insurance carrier is required to respond to expedited and standard requests for prior authorization for health care services, respectively. The bill prohibits a carrier from (i) denying a claim for the provision of dental services by a dentist or oral surgeon for failure to obtain prior authorization if the dentist or oral surgeon calls the dental plan during business hours to obtain such prior authorization and is unable to reach the dental plan or is placed on hold for longer than 15 minutes and (ii) downcoding a claim if a prior authorization was approved. The bill requires carriers to establish a system in which providers with high prior authorization approval rates are not required to obtain prior authorization for routine health care services. Additionally, the bill provides that if a prior authorization request is denied, the carrier is required to notify providers and enrollees if artificial-intelligence based tools were used in reviewing the request.
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.
Unregulated pregnancy clinics; unauthorized practice of medicine; unprofessional conduct of medical providers; civil penalty. Requires unregulated pregnancy clinics, as defined by the bill, to have a qualified medical provider who supervises and takes responsibility for the provision of all medical care at such facility. The bill provides that any such clinic is required to provide to a client, upon request, the name and contact information for the qualified medical provider who supervises medical care to such client. A clinic shall notify the Board of Health, in accordance with rules promulgated by the Board, of the name and contact information for its qualified medical providers. Any person who violates the provisions of the bill is subject to a civil penalty of up to $3,000 for a first violation and up to $10,000 for a second or subsequent violation. The bill provides that individuals licensed by the Board of Medicine or the Board of Nursing are subject to disciplinary action for making or knowing of certain willful representations of the care provided at such unregulated pregnancy clinics if such representations are not true.
Board of Health; Stillbirth Support Grant Program established. Establishes the Stillbirth Support Grant Program to provide grants to individuals who deliver a stillborn child, as defined in the bill, to assist with out-of-pocket expenses associated with such delivery. The bill authorizes the Board of Health to administer the Program and establish procedures and issue guidelines for administration of the Program as it deems appropriate. An application for such grant must be submitted within one year of delivery of a stillborn child.
