Healthcare

Department of Medical Assistance Services; Department of Social Services; Medicaid eligibility determination appeal time limit; mailed communications time period. Directs (i) the Department of Medical Assistance Services to amend its regulations to extend the time limit for appeals of eligibility determinations and (ii) the Department of Medical Assistance Services and the Department of Social Services to amend their regulations to create a mailing time period for communications related to Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance to Needy Families (TANF).

Department of Medical Assistance Services; Medicaid benefit for nutrition services programs; sunset. Directs the Department of Medical Assistance Services (the Department) to, conditional on the receipt of all necessary approvals and the securing of federal financial participation, implement a provision for payment of medical assistance for nutrition services programs which may include case management, nutrition counseling and instruction, home-delivered meals and pantry stocking, nutrition prescriptions, and grocery provisions. The bill directs the Department to prioritize the purchase and distribution of locally grown food wherever feasible. The implementation of nutrition services programs pursuant to the bill is conditional on the Department obtaining all necessary approvals and federal financial participation. The bill sunsets on July 1, 2027, if such approval and federal financial participation is not obtained.

Department of Medical Assistance Services; sickle cell disease; feasibility of Medicaid benefit and Medicaid Health Homes; report. Directs the Department of Medical Assistance Services to determine the feasibility of participating in an optional Medicaid benefit for sickle cell disease and establishing Medicaid Health Homes to coordinate care and provide treatment for individuals with sickle cell disease. The bill requires the Department to report its findings in its annual review of sickle cell disease treatment and submit such review to the Chairmen of the House Committee on Health and Human Services and the Senate Committee on Education and Health and the Joint Commission on Health Care by November 15, 2026.

Department of Medical Assistance Services; Family Access to Medical Insurance Security Plan; literacy pilot program. Directs the Department of Medical Assistance Services to seek the necessary permissions from the Centers for Medicare and Medicaid Services to authorize and fund a pilot program promoting early literacy and parental bonding as part of routine pediatric primary care visits in select underserved localities through a partnership with Reach Out and Read.

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.

Virginia Health Care Fund; additional funding and uses; emergency. Expands allowable funding sources of the Virginia Health Care Fund to include appropriated state general fund moneys and moneys from public and private sources. The bill allows moneys from the Fund to be used for financial assistance to organizations and service providers that provide health care services, or expand the provision of health care services, to populations protected by the Virginia Human Rights Act. The bill contains an emergency clause.