Healthcare

Health insurance; tobacco surcharge. Eliminates the authority of a health carrier to vary its premium rates based on tobacco use. Under current law, a health carrier may charge premium rates up to 1.5 times higher for a tobacco user than for a nonuser. The provisions of the bill apply to health benefit plans providing individual or small group health insurance coverage entered into, amended, extended, or renewed on or after January 1, 2027.

Department of Medical Assistance Services; Medicaid benefit for nutrition services programs; sunset. Directs the Department of Medical Assistance Services (the Department) to, conditional on the receipt of all necessary approvals and the securing of federal financial participation, implement a provision for payment of medical assistance for nutrition services programs which may include case management, nutrition counseling and instruction, home-delivered meals and pantry stocking, nutrition prescriptions, and grocery provisions. The bill directs the Department to prioritize the purchase and distribution of locally grown food wherever feasible. The implementation of nutrition services programs pursuant to the bill 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.

Public institutions of higher education; financial assistance; Medical Education Service Grant Program established; report. Establishes the Medical Education Service Grant Program (the Program) for the purpose of providing grants to any person enrolled in or admitted to an eligible institution, as defined in the bill, that shall be awarded in whole or in part upon satisfactory completion of a service agreement entered into by a recipient to engage in clinical practice in a designated service area, as defined in the bill, for the requisite period and in accordance with the requirements set forth by the bill. The bill directs the State Council of Higher Education for Virginia (the Council), in partnership with the Virginia Health Workforce Development Authority (the Authority), to administer the Program. The bill also (i) establishes requirements for the administration of the Program, including (a) requirements for eligibility to apply to and receive a grant under the Program and the prioritization of Program applications and (b) terms and conditions governing the awarding of grants under the Program; (ii) directs the Council and the Authority to establish policies and procedures for the administration of the Program relating to monitoring and enforcing compliance of recipients with Program requirements and terms and conditions; and (iii) directs the program administrator to annually collect data on the activities of the Program for the preceding fiscal year and submit to the Governor and the Chairs of the House Committees on Education, Health and Human Services, and Appropriations and the Senate Committees on Education and Health and Finance and Appropriations a report on such data by January 1 of each year in which funds are made available for the Program.

Prescription Drug Affordability Advisory Panel established; maximum fair price; annual reports; civil penalties. Directs the Secretary of Health and Human Resources to establish the Prescription Drug Affordability Advisory Panel to conduct data analyses, develop policy recommendations, and identify implementation barriers related to strategies to improve prescription drug affordability, enhance price transparency, and strengthen data collection practices for prescription drugs across public and private payers. The bill requires the Panel to (i) report annually on prescription drug pricing trends and any policy recommendations on legislation to improve prescription drug affordability and (ii) provide quarterly updates on prescription drug pricing trends. The bill requires each pharmacy benefits manager to provide to the Panel, upon request, certain information relating to the dispensation of a referenced drug, as defined in the bill.The bill prohibits prescription drug manufacturers or wholesale distributors permitted or licensed in the Commonwealth from accepting payment at an amount higher than the maximum fair price established by the U.S. Secretary of Health and Human Services pursuant to federal law for the sale of a referenced drug intended for use by individuals in the Commonwealth. Under the bill, an entity that violates such prohibition is subject to a civil penalty of $10,000 per violation. The bill also prohibits a manufacturer subject to its provisions from removing a referenced drug from sale distribution in the Commonwealth for the purpose of avoiding the impact of the bill's rate limitations without providing certain prior notice. Under the bill, a manufacturer that violates such prohibition on removing a referenced drug without the required notice is subject to a civil penalty equal to the greater of $100,000 or the total amount of annual savings for the referenced drug, as determined by the Board of Pharmacy. This bill is identical to SB 271.

Health insurance; limit on cost-sharing payments for prescription drugs under certain plans. Requires each carrier that offers a health plan in either the individual or small group market to ensure that at least one health plan in each of the bronze, silver, gold, and platinum levels of coverage in each rating area in the individual and small group market conform with the following: (i) a plan that offers a platinum level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $150 per 30-day supply of the prescription drug; (ii) a plan that offers a gold level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $200 per 30-day supply of the prescription drug; (iii) a plan that offers a silver level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $250 per 30-day supply of the prescription drug; and (iv) a plan that offers a bronze level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $300 per 30-day supply of the prescription drug. The bill requires that any plans offered to meet its requirements are (a) clearly and appropriately named to aid the consumer or plan sponsor in the plan selection process and (b) marketed in the same manner as other plans offered by the carrier. The bill's provisions apply to any individual or group accident and sickness insurance policy, any individual or group accident and sickness subscription contract, and any health care plan for health care services delivered, issued for delivery, or renewed in the Commonwealth on or after January 1, 2028. This bill is identical to HB 625.

Department of Social Services; Department of Behavioral Health and Developmental Services; Department of Health; prenatal and postnatal substance use; work group; report. Directs the Department of Social Services, Department of Behavioral Health and Developmental Services, and Department of Health to convene a work group to evaluate the Commonwealth's response to parental prenatal and postnatal substance use, the services available to address such substance use, and the effects of such substance use on newborns and children. The bill requires the work group to submit a written report of its findings and recommendations to the Chairs of the Senate Committees on Education and Health and Rehabilitation and Social Services and the House Committee on Health and Human Services by December 1, 2026. This bill is identical to SB 133.

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.

Obstructing reproductive health care facility; penalties. Creates a Class 1 misdemeanor for any person who (i) by force or threat of force, or by physical obstruction, intentionally injures, intimidates, or interferes with, or attempts to injure, intimidate, or interfere with, another person because such other person is or has been, or in order to intimidate such person or any other person or any class of persons from, obtaining or providing reproductive health services, defined in the bill, or (ii) intentionally damages or destroys, or attempts to damage or destroy, a reproductive health care facility, defined in the bill, because such facility provides reproductive health services. The bill also provides that the provisions of the bill shall not be construed to place any restriction on the content of any message that anyone may wish to communicate to anyone else, either inside or outside the regulated areas.

Health insurance; balance billing protection; emergency medical services vehicle transportation. Prohibits an out-of-network health insurance provider from balance billing any enrollee for transportation provided by an emergency medical services vehicle, defined in the bill as any vehicle, vessel, or aircraft that holds a valid permit issued by the Office of Emergency Medical Services and that is equipped, maintained, or operated to provide emergency medical care or transportation of patients who are sick, injured, wounded, or otherwise incapacitated or helpless.