Department of Medical Assistance Services; Family Access to Medical Insurance Security Plan; literacy pilot program. Directs the Department of Medical Assistance Services to seek the necessary permissions from the Centers for Medicare and Medicaid Services to authorize and fund a pilot program promoting early literacy and parental bonding as part of routine pediatric primary care visits in select underserved localities through a partnership with Reach Out and Read.
Inspection of certified nursing facilities; compliance with federal reporting requirements; civil penalty. Directs the Department of Health to include validation of compliance with federal reporting requirements in its inspection process for certified nursing facilities. The bill requires certified nursing facilities to submit a quarterly report detailing (i) all self-reported incidents and compliance issues submitted to the Centers for Medicare and Medicaid Services during the preceding quarter; (ii) any corrective actions taken in response to self-reported incidents; and (iii) updates on ongoing investigations related to reported incidents. The Department may impose a penalty on a certified nursing facility that fails to comply with the reporting requirements imposed by the bill, which may include a civil penalty not to exceed $1,000, increased frequency of inspections, and suspension or revocation of the certified nursing facility's license.
Department of Medical Assistance Services; Medicaid waivers; consumer-directed services; employer of record. Directs the Department of Medical Assistance Services (DMAS) to modify the program rules for consumer-directed services available through certain Medicaid waivers to allow an individual receiving services to serve as the employer of record (EOR) for his own service delivery and designate another individual to perform all or a portion of the duties of the EOR on the individual's behalf when the individual receiving services is unable to perform such duties or direct his own care. The bill specifies that when an individual (i) has not yet reached the age of majority, (ii) is ineligible to use his existing employer identification number (EIN) to facilitate the taxation of benefits, or (iii) is otherwise determined to be ineligible by DMAS by administrative rule, the EIN shall be assigned to the individual receiving services and shall not be transferred to another individual. Under the bill, DMAS has the authority to limit such amendments to specify that an individual receiving services may make such designation no more than twice per calendar year.
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.
Department of Medical Assistance Services; community health worker expansion. Directs the Department of Medical Assistance Services, in coordination with the Department of Health, Department of Social Services, Department of Behavioral Health and Developmental Services, and Department for Aging and Rehabilitative Services, to (i) evaluate opportunities for Medicaid managed care organizations to embed certified community health workers into care coordination models, (ii) evaluate the implementation of 2024 Medicare Community Health Integration services codes, (iii) develop and implement statewide workforce pathways for community health worker training, and (iv) identify opportunities to expand the use of community health workers in programs supporting high-cost Medicaid populations. The bill directs the Department of Medical Assistance Services to submit a report of its findings and recommendations to the Joint Commission on Health Care and the Chairs of the House Committee on Appropriations and Senate Committee on Finance and Appropriations no later than December 1, 2026.
Department of Medical Assistance Services; Department of Social Services; Medicaid eligibility determination appeal time limit; mailed communications time period. Directs (i) the Department of Medical Assistance Services to amend its regulations to extend the time limit for appeals of eligibility determinations and (ii) the Department of Medical Assistance Services and the Department of Social Services to amend their regulations to create a mailing time period for communications related to Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance to Needy Families (TANF).
Department of Medical Assistance Services; consultation with federally recognized tribes. Establishes a Tribal Medicaid Advisory Group to work collaboratively on (i) plan amendments, waiver requests, and policies affecting tribal health programs at least 60 days prior to submitting them for public notice and comment and (ii) a tribal health program billing manual. The advisory group is required to meet in person on at least a quarterly basis. The bill also requires the Department of Medical Assistance Services to (a) recognize the eligibility of any tribal health program to participate as a provider in the state plan, (b) consult with any tribal health program participating in the state plan at least 60 days prior to taking any adverse action, including suspension of payments or investigation regarding the participation of any tribal health program in the state plan, and (c) engage in ongoing consultation with federally recognized tribes and tribal health programs to address the needs of the state and tribal governments. This bill is a recommendation of the Commission on Updating Virginia Law to Reflect Federal Recognition of Virginia Tribes.
Department of Medical Assistance Services; community health workers in Medicaid managed care; report. Directs the Department of Medical Assistance Services (DMAS) to evaluate and develop recommendations for a statewide strategy to integrate community health workers into Medicaid managed care and related health and human services programs. The bill instructs DMAS to consult with the Department of Health, the Department of Social Services, the Department of Behavioral Health and Developmental Services, the Department for Aging and Rehabilitative Services, the Virginia Community Health Worker Association, Medicaid managed care organizations, local departments of social services, community-based providers, and other relevant stakeholders. The bill requires DMAS to submit a report of its findings and recommendations to the Joint Commission on Health Care and the Chairs of the House Committee on Appropriations and the Senate Committee on Finance and Appropriations by December 1, 2026.
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.
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.
