Healthcare

Health insurance; notice of adverse determination. Requires health carriers to send in writing to a covered person the notice of an adverse determination or final adverse determination and the covered person's right to request an external review, as required by current law, within five business days after the adverse determination or final adverse determination has been made. The bill also requires such notice to include certain information related to the person who made the adverse determination or final adverse determination.

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.

Recovery residences; regulations. Establishes certain requirements for recovery residences and directs the State Board of Behavioral Health and Developmental Services (the Board) to promulgate regulations to establish minimum certification standards for recovery residences. The bill also requires that the regulations promulgated by the Department of Behavioral Health and Developmental Services (the Department) related to the certification of recovery residences include provisions that no recovery residence, or operator, employee, or agent of a recovery residence, may require a resident to participate in medical or psychological services, including clinical substance use treatment, that such recovery residence receives financial benefit from, either directly or indirectly, as a condition of entering or continuing residence at such recovery residence. The bill requires the Department to monitor credentialing agencies providing credentials to recovery residences to ensure criteria related to certification comply with regulations and specifies that no such credentialing agency shall provide credentials to a recovery residence that is owned or operated by an individual who is employed by or in a position of authority at such credentialing agency, or an immediate family member of any such individual. The bill also requires that referrals to recovery residences made by the Department, any agency of the Commonwealth, or by a court may only be made to recovery residences that are certified. This bill is identical to SB 270.

Youth Health Protection Act established; civil penalty. Creates the Youth Health Protection Act, which makes it unlawful for any individual to provide gender transition procedures, defined in the bill, for minors and prohibits the use of public funds for gender transition procedures. The bill allows parents, guardians, or custodians to withhold consent for any treatment, activity, or mental health care services that are designed or intended to form their child's conceptions of sex and gender or to treat gender dysphoria or gender nonconformity. The bill prohibits government agents, other than law-enforcement personnel, from encouraging or coercing a minor to withhold information from the minor's parent. The bill establishes a duty for a government agent with knowledge that a minor has exhibited symptoms of gender dysphoria or gender nonconformity or otherwise demonstrates a desire to be treated in a manner incongruent with the minor's sex to immediately notify each of the minor's parents, guardians, or custodians in writing, with descriptions of relevant circumstances. The bill prohibits discrimination against persons (i) providing information regarding violations of the Act to their employer or specified public entities or (ii) who make disclosures under the Act of information that evinces any violation of law, rule, or regulation; any violation of any standard of care or other ethical guidelines for the provision of health care service; or gross mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety. The bill establishes a civil action for any violation of the Act by a clinic, health care system, medical professional, or other responsible person with a two-year statute of limitations. The bill prohibits political subdivisions of the Commonwealth from enacting, adopting, maintaining, or enforcing any measure that interferes with the professional conduct and judgment of a mental health care professional or counselor undertaken within the course of treatment and communication with clients, patients, other persons, or the public. The bill provides for enforcement by the Attorney General or a mental health care professional or counselor through an action for injunctive relief and allows a mental health care professional to recover reasonable attorney fees and reasonable costs incurred in obtaining an injunction. The bill waives sovereign immunity to suit and immunity from liability under this statute.

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.

Health insurance; mandated benefits; treatment of menopause and perimenopause. Requires each insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; each corporation providing individual or group accident and sickness subscription contracts; and each health maintenance organization providing a health care plan for health care services to provide coverage for medically necessary treatment and care for menopause and perimenopause, as described in the bill.

Health insurance; ethics and fairness in carrier business practices; downcoded claims. Prohibits a carrier, intermediary, administrator, or representative of a carrier from downcoding a claim unless the decision to downcode is determined by a person or electronic system that reflects correct coding standards and considers all relevant patient data from the billing provider in making the determination. The bill requires a carrier, intermediary, administrator, or representative that downcodes a claim to provide certain notice to the provider. The bill requires that all downcoding dispute decisions are reviewed and adjudicated by a natural person.

Use of artificial intelligence system by mental health service providers; civil penalty. Permits the use of an artificial intelligence system by mental health service providers to assist in providing therapy or counseling services if such mental health service provider maintains full responsibility for all interactions, outputs, and data use associated with the system. The bill prohibits the use of an artificial intelligence system to provide therapy or counseling services without a mental health service provider. The bill specifies that records kept by mental health service providers must comply with health records privacy requirements; creates an exception for religious counseling, peer support, or self-help materials and educational resources; and establishes a civil penalty not to exceed $10,000 for violations of the statute.

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.

Board of Pharmacy; compounding pharmacies; use of bulk drug substances; recordkeeping. Establishes additional requirements for when pharmacists may use bulk drug substances in compounding and specifies prohibitions on pharmacist use of (i) bulk drug substances that were withdrawn or removed from the market for reasons of safety and effectiveness or were covered by an investigational new drug application and not approved and (ii) compounded drug products that are essentially a copy of commercially available drug products. The bill permits the Board of Pharmacy to request records of all compounded drug products and requires pharmacists to furnish such records within 48 hours of such request or within a reasonable time as determined by the Board. The bill also permits the Board of Pharmacy to submit any information related to investigations, disciplinary proceedings, or inspection of a licensee to the National Association of Boards of Pharmacy.