Healthcare (Insurance)

Health insurance; reporting requirements. Amends various reporting requirements related to health insurance, including by requiring the State Corporation Commission to maintain and publicly post an inventory of mandated benefits and providers, requiring health carriers to report annually on provider terminations and reinstatements, and consolidating reports related to balance billing and arbitration. The bill repeals reporting requirements related to the Comparable Health Care Service Incentive Program and Virginia Health Savings Account Plan.

Virginia National Guard TRICARE Reimbursement Fund established. Establishes the Virginia National Guard TRICARE Reimbursement Fund for the purpose of reimbursing the costs of federal TRICARE dental insurance plan premiums and TRICARE Reserve Select health insurance plan premiums for Virginia National Guard members deemed eligible by the Adjutant General.

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.

Health insurance; ensuring fairness in cost-sharing; pharmacy benefits managers; compensation and duties: civil penalty. Amends provisions related to rebates provided by carriers and health benefit plans to health plan enrollees by defining "defined cost-sharing," "pharmacy benefits management services," and "price protection rebates." The bill requires that an enrollee's defined cost-sharing for each prescription drug be calculated at the point of sale based on a price that is reduced by an amount equal to at least 80 percent of all rebates received or expected to be received in connection with the dispensing or administration of the prescription drug. The bill prohibits a pharmacy benefits manager from deriving income from pharmacy benefits management services provided to a carrier or health benefit plan except for income derived from a pharmacy benefits management fee. The bill requires the amount of any pharmacy benefits management fees to be set forth in the agreement between the pharmacy benefits manager and the carrier or health benefit plan and that such fee not be based on the acquisition cost or any other price metric of a drug; the amount of savings, rebates, or other fees charged, realized, or collected by or generated based on the activity of the pharmacy benefits manager; or the amount of premiums, deductibles, or other cost-sharing or fees charged, realized, or collected by the pharmacy benefits manager from enrollees or other persons on behalf of an enrollee. The bill requires a pharmacy benefits manager to annually certify to the State Corporation Commission that it has met certain requirements. The Commission is directed to impose a civil penalty not to exceed $1,000 per claim for a violation of these provisions. The bill establishes a pharmacy benefits manager duty, which includes the duties of care, good faith, and fair dealing, owed to any enrollee, provider, or health benefit plan that receives pharmacy benefits management services from the pharmacy benefits manager or that furnishes, covers, receives, or is administered a unit of a prescription drug for which the pharmacy benefits manager has provided pharmacy benefits management services. The bill requires the Commission to define by regulation the scope of such duty and provides for a private cause of action for any person aggrieved by the breach of such duty.

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 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.

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.

Health insurance; essential health benefits benchmark plan. Requires the Bureau of Insurance to select a new essential health benefits benchmark plan for the 2028 plan year, or the soonest plan year thereafter as permitted by the Centers for Medicare and Medicaid Services, that includes, in addition to the essential health benefits package included in the existing benchmark plan, coverage for (i) doula care services; (ii) the treatment of iatrogenic infertility; (iii) fertility treatment and diagnosis, including a maximum of three cycles per lifetime of assisted reproductive technology; (iv) hearing aids for individuals of all ages; (v) pasteurized donor human breast milk; (vi) the prophylaxis, diagnosis, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome; and (vii) the treatment of polycystic ovary syndrome. Such mandate for coverage does not apply to the individual or small group markets. The bill has a delayed effective date pursuant to approval by the Centers for Medicare and Medicaid Services of certain coverage as outlined in the bill. As introduced, this bill was a recommendation of the Health Insurance Reform Commission.