Healthcare (Insurance)

Health insurance; coverage for the treatment of acquired brain injury required. Requires health insurance carriers to provide coverage for the treatment of acquired brain injury that includes coverage for treatment using cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy, neuropsychological testing, neurofeedback therapy, functional rehabilitation therapy, community reintegration services, post-acute residential treatment services, inpatient services, outpatient and day treatment services, and home and community-based treatment.

Health insurance; carrier contracts; required provisions regarding prior authorization for prescription drugs. Amends existing required provisions for health carrier contracts related to prior authorizations for prescription drugs. Current law requires that if prior authorization is approved for prescription drugs and such prescription drugs have been scheduled, provided, or delivered to the patient consistent with the authorization, health carriers may not revoke, limit, condition, modify, or restrict that authorization except in certain circumstances. The bill requires this limitation on carriers to apply for the duration of the authorization, which the bill requires to be a minimum of six months for initial authorizations and a minimum of 12 months for continued authorizations. The bill adds circumstances under which a prior authorization may be revoked, limited, conditioned, modified, or restricted by a carrier, including (i) a final action by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer communicating a patient efficacy issue that would affect the authorization and (ii) when additional safety and efficacy monitoring is clinically appropriate or recommended by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer.

Health insurance; requirements for certain opioid antagonists. Requires each health insurer, corporation providing health care subscription plans, and health maintenance organization whose policy, contract, or plan includes coverage for prescription drugs to include coverage for at least one opioid antagonist used for overdose reversal dispensed pursuant to an oral, written, or standing order of a prescriber and ensure that cost-sharing for at least one opioid antagonist used for overdose reversal is included on the lowest cost tier of the insurer's, corporation's, or health maintenance organization's prescription drug formulary. The bill provides that such coverage shall be exempt from any prior authorization or step therapy requirement on coverage of benefits. As introduced, this bill was a recommendation of the Joint Commission on Health Care. This bill is identical to HB 795.

Health insurance; application of cost-sharing prohibitions. Provides that provisions of state law that prohibit a health insurance carrier from imposing a cost-sharing requirement on an enrollee for receiving a health care service (i) apply only when such enrollee receives such health care service from a participating provider under the health benefit plan and (ii) do not apply if the application of such prohibition would disqualify a high-deductible health benefit plan from eligibility for a health savings account under federal law.

Nursing homes and certified nursing facilities; required liability insurance coverage. Provides that the regulations of the Board of Health shall require purchasers of licensed nursing homes or certified nursing facilities with claims-made policies of liability insurance coverage to purchase an extended reporting endorsement of two years after the date of sale or to purchase liability insurance coverage with dates that begin two years prior to the date the existing owner's policies end.

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.

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.

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; 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.