Healthcare

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.

Insurance; Fire Programs Fund; purposes; Virginia At Risk Fire Grant Program established. Increases the assessment on certain insurance companies from one percent to 1.5 percent. The bill provides that the portion of the Fire Programs Fund allocated to localities may be used for the additional purposes of (i) constructing, improving, or expanding fire station facilities; (ii) providing mental health resources for fire personnel; or (iii) hiring additional fire personnel and funding recruitment and retention programs. The bill also prohibits such funds from being used, except as provided, for the purposes of investments, operating expenses, debt repayment, taxes, or fees. The bill also establishes the Virginia At Risk Fire Grant Program, to be funded by 0.25 percent of the assessments on insurance companies, for the purposes of providing assistance to localities with fire departments that are determined to be most at risk of being unable to provide fire suppression or rescue activities or maintain compliance with relevant laws and regulations.

Workers' compensation; presumption for certain cancers; sheriffs and deputy sheriffs. Expands the workers' compensation presumption of compensability for certain cancers causing the death or disability of certain employees who have completed five years of service in their position to include sheriffs or deputy sheriffs.

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.

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.

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 for administrative support and supplementary support, as those terms are defined in the bill, and 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.

Health insurance; coverage for the treatment of acquired brain injury required. Requires health insurance carriers to provide coverage for the treatment of acquired brain injury that includes coverage for treatment using cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy, neuropsychological testing, neurofeedback therapy, functional rehabilitation therapy, community reintegration services, post-acute residential treatment services, inpatient services, outpatient and day treatment services, and home and community-based treatment.

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.

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.

Health insurance; coverage for speech therapy as a treatment for stuttering. Requires health insurance carriers whose health care plans include coverage for habilitative services and rehabilitative services, as such terms are defined in the bill, to provide coverage for habilitative speech therapy and rehabilitative speech therapy, as such terms are defined in the bill, as a treatment for stuttering. The bill provides that such coverage is not (i) subject to any maximum annual benefit limit, including any limits on the number of visits an insured may make to a speech-language pathologist; (ii) limited based on the type of disease, injury, disorder, or other medical condition that resulted in the stuttering; or (iii) subject to utilization review or utilization management requirements, including prior authorization or a determination that the habilitative or rehabilitative speech therapy services are medically necessary. The bill applies to health care plans delivered, issued for delivery, or renewed on and after January 1, 2027.