Healthcare

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.

Hospitals; reports of threats or acts of violence against health care providers; expansion of reporting requirements. Expands the reporting requirements for incidents of workplace violence in hospitals with an emergency department by requiring additional descriptors of incidents, requiring hospitals to report collected data to additional parties, and directing the Department of Health to publish a report containing an annual summary of such data. The bill directs the Board of Health to promulgate regulations implementing the provisions of the bill by January 1, 2027, and directs the Department of Health to publish its first report by December 31, 2027.

Breakthrough Therapies for Veteran Suicide Prevention Act; fund and council established; report. Establishes the Breakthrough Therapies for Veteran Suicide Prevention Fund (the Fund) to provide funding to support clinical research and implementation of FDA Breakthrough Therapies, defined in the bill, for the treatment of post-traumatic stress disorder, treatment-resistant depression, major depressive disorder, and traumatic brain injury. Under the bill, the Fund shall be used to (i) establish public-private partnerships to jointly fund Phase III clinical trials of FDA Breakthrough Therapies; (ii) conduct investigator-initiated clinical trials; (iii) establish a compassionate use program; (iv) create education and training opportunities for mental health professionals; (v) begin patient access pilot programs; and (vi) conduct implementation studies for best practices, cost-effectiveness, and methods to reduce treatment costs. The bill also establishes the Breakthrough Therapies for Veteran Suicide Prevention Advisory Council to advise the Department of Health on administration of grant funding or contracting to carry out the purposes of the Fund. Finally, the bill requires the Board of Pharmacy to amend its regulations to designate, reschedule, or deschedule a controlled substance in accordance with federal law after the expiration of 30 days from the publication in the Federal Register of a final or interim final order or rule.

Health insurance; cost-sharing payments for insulin and diabetes equipment and supplies; limit. Decreases the cap on the cost-sharing payment that a covered person is required to pay for a covered prescription insulin drug from $50 to $35 for a 30-day supply of the prescription insulin drug and provides such cap is an aggregate cap that applies in situations where the covered person is prescribed more than one insulin drug. The bill also establishes such an aggregate cap of $35 for a 30-day supply of diabetes equipment and supplies.

Line of Duty Act; transitional coverage. Requires the Department of Human Resource Management to acquire and provide temporary transitional health insurance coverage to disabled persons, eligible spouses, and eligible dependents during the period of transition into the LODA (Line of Duty Act) Health Benefits Plans. Current law authorizes but does not require the Department to acquire and provide such temporary transitional health insurance coverage to disabled persons, eligible spouses, and eligible dependents during such period.