Healthcare (Insurance)

State retiree health benefits program; reenrollment in program. Allows a state retiree who elects to participate in the state retiree health plan but later discontinues participation one opportunity to return to participation in the plan, provided that such return to participation occurs within five years after the date of such employee's retirement. Under current law, a state retiree who elects to participate in the state retiree health plan but later discontinues participation is barred from participating in the plan.

Supervised billing; Medicaid and health insurance plans. Requires the Department of Medical Assistance Services to permit a qualified licensed provider to bill for clinical services provided by a qualified non-licensed provider under the supervision of the qualified licensed provider and requires health insurance carriers to provide coverage for mental health services or substance use services provided by a qualified non-licensed provider under the supervision of a qualified licensed provider when such services would be covered if provided by a qualified licensed provider. Additionally, the bill reduces the time limit for a retroactive denial by a health insurance carrier from 12 months to 180 days.

Health insurance; coverage for non-opioid prescription drugs. Prohibits a health insurance carrier from imposing any cost-sharing, prior authorization, step therapy, or other limitation on coverage of a covered non-opioid drug approved by the U.S. Food and Drug Administration for the treatment or management of pain that is more restrictive or less favorable to the enrollee relative to a covered opioid drug approved by the U.S. Food and Drug Administration for the treatment or management of pain.

Pharmacy benefits managers; requirements; scope; report. Requires all health insurance carriers to use the pass-through pricing model and may limit a pharmacy benefits manager from deriving income from pharmacy benefits management services provided to a carrier except for income derived from a pharmacy benefits management fee. The bill prohibits a pharmacy benefits manager from (i) reversing and or resubmitting the claim of a pharmacist or pharmacy without meeting certain requirements, (ii) reducing any payment to a pharmacist or pharmacy to an effective rate of reimbursement, or (iii) retroactively denying or reducing a claim or aggregate of claims except under certain circumstances. The bill requires the State Corporation Commission (the Commission) to examine the practice of carriers or pharmacy benefits managers requiring or inducing covered individuals to utilize pharmacy services at an affiliated pharmacy. The Commission is required to report its findings and recommendations to the General Assembly by December 1, 2027. Certain provisions of the bill have a delayed effective date of July 1, 2027. This bill is identical to SB 669.

Health insurance; tobacco surcharge. Eliminates the authority of a health carrier to vary its premium rates based on tobacco use. Under current law, a health carrier may charge premium rates up to 1.5 times higher for a tobacco user than for a nonuser. The provisions of the bill apply to health benefit plans providing individual or small group health insurance coverage entered into, amended, extended, or renewed on or after January 1, 2027. This bill is identical to HB 220.

Pharmacy freedom of choice; specialty pharmacy benefits. Provides that in no event shall any person receiving a covered specialty pharmacy benefit from a nonpreferred or nonparticipating provider, regardless of whether it has submitted a reimbursement agreement, be responsible for amounts that may be charged by the nonpreferred or nonparticipating provider in excess of the copayment and the insurer's reimbursement applicable to all of its preferred or participating pharmacy providers.

Commonwealth Health Reinsurance Program; extension of program; percentage goal to decrease premium. Directs the State Corporation Commission to apply to the appropriate federal agencies under the federal Patient Protection and Affordable Care Act for an extension of the existing State Innovation Waiver authorizing the Commonwealth to implement a reinsurance program. The existing State Innovation Waiver is set to expire on January 1, 2028. Additionally, the bill removes the 20 percent upper limit of the premium reduction goal under the Commonwealth Health Reinsurance Program. As introduced, this bill was a recommendation of the Health Insurance Reform Commission.

Health insurance; coverage for contraceptive drugs and devices. Requires health insurance carriers to provide coverage, under any health insurance contract, policy, or plan that includes coverage for prescription drugs on an outpatient basis, for contraceptive drugs and contraceptive devices approved by the U.S. Food and Drug Administration, including those available over-the-counter. The bill prohibits a health insurance carrier from imposing upon any person receiving prescription contraceptive benefits pursuant to the provisions of the bill any copayment, coinsurance payment, or fee, except in certain circumstances. Additionally, the bill requires any health benefit plan that provides coverage for hormonal contraceptives to provide point-of-sale coverage without cost-sharing at in-network pharmacies for hormonal contraceptives available over-the-counter. This bill is identical to SB 361.

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; pharmacy benefits managers; requirements and prohibited conduct; retail pharmacy network access standards; enforcement; civil penalty. Amends the definition of "pharmacy benefits management" to exclude certain activities and amends certain provisions related to prohibited conduct by health carriers and pharmacy benefits managers (PBMs). The bill prohibits a health carrier or PBM from denying a pharmacy the opportunity to participate in a network at preferred status if the pharmacy is willing to accept the same terms and conditions as other pharmacies that receive preferred status. The bill prohibits a health carrier or PBM from retroactively denying or reducing reimbursement for a covered service claim, except in certain circumstances. The bill also prohibits health carriers and PBMs from failing to make a payment due to a pharmacy or pharmacist upon termination from a network and from charging a pharmacist or pharmacy a fee related to participation in a PBM's network. Under the bill, no PBM shall restrict a pharmacy from informing an individual of any differential between the individual's out-of-pocket costs and the amount the individual would pay to purchase the drug directly or through the individual's health insurance coverage. The bill also requires PBMs to establish and maintain an electronic claim inquiry processing system using national standards to provide certain disclosures and to maintain records of network development activities. The bill prohibits a PBM from including the name of any pharmacy or hospital in any material issued by the PBM unless it lists all pharmacies participating in the preferred and nonpreferred pharmacy and health networks. Under the bill, the Attorney General is authorized to issue civil investigative demands regarding violations of the provisions of the bill and to bring an action in circuit court to enjoin any violation of such provisions. If the court finds that a person has willfully violated the provisions of the bill, the Attorney General may assess a civil penalty of up to 5,000 per violation.