Healthcare (Insurance)

Health insurance; prior authorization; required contract provisions; work group. Requires any provider contract between a carrier and a participating health care provider or its contracting agent to contain specific provisions that (i) require a carrier to establish and maintain a prior authorization application program interface for processing prior authorization requests and (ii) require a participating health care provider to ensure that any electronic health record or health information technology system owned by or contracted for the provider to maintain the health record of an enrollee has the ability to access such application program interface. The bill amends requirements for the existing work group on electronic prior authorization.

Health insurance; coverage for doula care services. Requires health insurers, corporations providing health care subscription contracts, and health maintenance organizations whose policy, contract, or plan includes coverage for obstetrical services to provide coverage for doula care services provided by a state-certified doula. The bill requires such coverage to include coverage for at least eight visits during the antepartum or postpartum period and support during labor and delivery. The bill provides that health insurance carriers are (i) not required to pay for duplicate services actually rendered by both a state-certified doula and another health care provider and (ii) prohibited from requiring supervision, signature, or referral by any other health care provider as a condition of reimbursement for doula care services, except when those requirements are also applicable to other categories of health care providers.

Health insurance; pharmacies; freedom of choice; delivery of prescription drugs; penalties. Prohibits an insurer, health maintenance organization, corporation providing preferred provider subscription contracts, or pharmacy benefits manager from imposing upon any person receiving pharmaceutical benefits any policy or practice requiring or incentivizing certain provisions relating to the delivery of prescription drugs. A violation of the bill's provisions constitutes an unfair trade practice under existing law and is subject to injunctive, penalty, and enforcement provisions in existing law.

Health insurance; coverage for maternal mental health screenings. Requires health insurance carriers to provide coverage for maternal mental health screenings. The bill requires such coverage to include at least one maternal mental health screening to be conducted during pregnancy, at least one additional screening to be conducted during the first six weeks of the postpartum period, and additional medically necessary postpartum screenings. Additionally, the bill provides that coverage for a prescription drug for the treatment of a maternal mental health condition shall not be subject to prior authorization requirements unless there are clinically significant safety or efficacy concerns.

Medical malpractice information disclosures; report. Requires insurers who issue medical malpractice liability insurance polices covering health care providers in the Commonwealth to disclose, for the preceding calendar year, information regarding (i) premiums; (ii) claims activity; (iii) claim payments and litigation costs; and (iv) insurer financial condition. The bill further requires every hospital or health system licensed in the Commonwealth that maintains self-insurance, captive insurance, risk retention arrangements, or other retained financial risk for medical malpractice liability to disclose information regarding (a) the numbers of physicians and health care providers covered under the malpractice liability program; (b) claims activity; (c) malpractice expenditures; and (d) the total malpractice liability expenditures for the reporting year. The bill further requires such insurers, hospitals, and health care systems to provide a list of verdicts during the reporting year in medical malpractice actions in which the jury verdict exceeded the medical malpractice limitation on recovery. The bill provides that such disclosures and information be submitted to the Chairs of the House and Senate Committees for Courts of Justice and to the ranking Delegate and Senator of the minority party serving on such Committees on or before September 1, 2026, for the 2025 calendar year and on or before March 31 of each year thereafter for the preceding calendar year.

Comprehensive children's health care coverage program. Directs the Department of Medical Assistance Services (the Department) to establish a program to provide state-funded comprehensive health care coverage for individuals in the Commonwealth who are (i) under 19 years of age and (ii) not covered under a group health plan or health insurance coverage, or otherwise eligible for medical assistance services through the Commonwealth's program of medical assistance services established pursuant to Title XIX or XXI of the Social Security Act. The bill also requires the Department to ensure that all program information is made available in a manner that is accessible to individuals with limited English proficiency and individuals with disabilities through the provision of language access services, including oral interpretation and written translation, free of charge and to ensure that information obtained by the program remains confidential and is not disclosed for any purpose not related to the administration of the program or any purpose related to civil immigration enforcement unless the subject of the information consents to such disclosure or the requesting agency presents a valid judicial order, subpoena, or warrant. The bill requires the Department to seek all federal waivers and other approvals necessary to maximize federal financial participation in the cost of carrying out the program established by the bill.

Health insurance; carrier business practices; electronic attachments. Provides that, in the following contexts, information may be submitted by a provider to a health insurance carrier through electronic attachment, as defined in the bill: (i) information related to services rendered as required by the carrier in its provider contract; (ii) information related to any defect or impropriety that prevents the carrier from deeming a health insurance claim a clean claim, as defined in existing law; and (iii) information required to establish medical necessity, benefit coverage, or prior authorization of services, or to conduct reconsideration activities. The bill has a delayed effective date of January 1, 2027. This bill is identical to HB 676.

Health insurance; treatment of cancer and certain diseases; coverage of certain medications. Requires an insurer, corporation providing preferred provider subscription contracts, or health maintenance organization that provides coverage for drugs approved by the Food and Drug Administration and prescribed for the treatment of cancer or diseases of the blood to allow, at the patient's direction, (i) provider-administered drugs for such treatment to be dispensed by an in-network treating provider consistent with a provider agreement; (ii) provider-administered drugs for such treatment to be dispensed by an in-network treating provider when there is a documented delay of at least three days in the delivery of a medication from the designated specialty pharmacy; and (iii) self-administered drugs for such treatment to be sent to the pharmacy of the patient's choosing.

Mental health and substance abuse disorders; network adequacy standards; comparative analyses; report; emergency regulations. Directs the Department of Health to issue regulations that include quantitative network adequacy standards for timely access to care, travel time, and geographical distance that are at least as stringent as those imposed for qualified health plans and qualified dental plans. The bill amends the definitions of "mental health services" and "substance abuse services" for the purposes of health insurance coverage. The bill requires health carriers to submit all comparative analyses prepared pursuant to federal law to the Bureau of Insurance on the date and frequency as specified by the Bureau and includes additional information to include in such submission. Under the bill, the Bureau may impose a penalty not to exceed $100,000 for a noncompliant or insufficient comparative analysis or require a carrier to remove, revise, or remedy noncompliant treatment limitations. The bill also amends the contents of the annual report submitted by the Bureau to the General Assembly to cover enforcement efforts with respect to the federal Mental Health Parity and Addiction Equity Act of 2008.The bill authorizes the Bureau to promulgate regulations as necessary to implement the provisions of the bill and directs the Department of Health to adopt emergency regulations to implement the provisions of the bill. The bill directs the Department of Human Resource Management to evaluate the impact of the proposed changes to the provisions of the bill related to health insurance. The provisions of the bill related to health insurance have a delayed effective date of July 1, 2027. This bill is identical to SB 524.

Health insurance; coverage for standard fertility preservation procedures. Requires health insurance carriers to provide coverage for standard fertility preservation procedures. The bill provides that "standard fertility preservation procedures" means procedures to preserve fertility that are consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine or the American Society of Clinical Oncology for a person who has cancer, sickle cell disease, or other medical condition or is expected to undergo medication therapy, surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment to fertility.