Healthcare

Health insurance; limit on cost-sharing payments for prescription drugs under certain plans. Requires each carrier that offers a health plan in either the individual or small group market to ensure that at least one health plan in each of the bronze, silver, gold, and platinum levels of coverage in each rating area in the individual and small group market conform with the following: (i) a plan that offers a platinum level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $150 per 30-day supply of the prescription drug; (ii) a plan that offers a gold level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $200 per 30-day supply of the prescription drug; (iii) a plan that offers a silver level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $250 per 30-day supply of the prescription drug; and (iv) a plan that offers a bronze level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $300 per 30-day supply of the prescription drug. The bill requires that any plans offered to meet its requirements are (a) clearly and appropriately named to aid the consumer or plan sponsor in the plan selection process and (b) marketed in the same manner as other plans offered by the carrier. The bill's provisions apply to any individual or group accident and sickness insurance policy, any individual or group accident and sickness subscription contract, and any health care plan for health care services delivered, issued for delivery, or renewed in the Commonwealth on or after January 1, 2028. This bill is identical to HB 625.

Department of Social Services; Department of Behavioral Health and Developmental Services; Department of Health; prenatal and postnatal substance use; work group; report. Directs the Department of Social Services, Department of Behavioral Health and Developmental Services, and Department of Health to convene a work group to evaluate the Commonwealth's response to parental prenatal and postnatal substance use, the services available to address such substance use, and the effects of such substance use on newborns and children. The bill requires the work group to submit a written report of its findings and recommendations to the Chairs of the Senate Committees on Education and Health and Rehabilitation and Social Services and the House Committee on Health and Human Services by December 1, 2026. This bill is identical to HB 652.

Pharmaceutical Substance Manufacturing Grant Fund. Establishes the Pharmaceutical Substance Manufacturing Grant Fund to provide grant installment awards between July 1, 2026, and July 1, 2045, in an amount not to exceed $34 million per fiscal year and in an aggregate amount not to exceed $191,255,000, to a qualified company that (i) engages in the manufacture of pharmaceutical substances, (ii) executes a memorandum of understanding with the Commonwealth, and (iii) is expected to make a capital investment of at least $4 billion and create and maintain at least 500 new full-time jobs. This bill is identical to HB 1076.

Department of Health; State Health Commissioner; nursing homes; periodic medical visits and resident assessments; oversight and accountability. Requires all nursing homes to notify the resident of a nursing home, the resident's family, and the Department of Health if a federally required physician visit does not take place. The bill also requires each nursing home to conduct a comprehensive assessment on an annual basis to determine each resident's needs and describe each resident's capability to perform daily life functions. Such assessments must be reviewed at least once every 92 days, and more frequently in the event of a significant change in the resident's physical or mental condition. The bill directs the Department of Health and State Health Commissioner to take steps to improve care quality, protect residents, and strengthen oversight and accountability of nursing homes in the Commonwealth. The bill directs the Department to enhance recruitment efforts and expand workforce capacity in the Office of Licensure and Certification, accelerate training and onboarding initiatives, and explore measures to reduce administrative burdens. The bill requires the Commissioner to submit an annual report with recommendations for continuing improvement of nursing home quality and oversight. This bill incorporates SB 555.

Prescription Drug Affordability Advisory Panel established; maximum fair price; annual reports; civil penalties. Directs the Secretary of Health and Human Resources to establish the Prescription Drug Affordability Advisory Panel to conduct data analyses, develop policy recommendations, and identify implementation barriers related to strategies to improve prescription drug affordability, enhance price transparency, and strengthen data collection practices for prescription drugs across public and private payers. The bill requires the Panel to (i) report annually on prescription drug pricing trends and any policy recommendations on legislation to improve prescription drug affordability and (ii) provide quarterly updates on prescription drug pricing trends. The bill requires each pharmacy benefits manager to provide to the Panel, upon request, certain information relating to the dispensation of a referenced drug, as defined in the bill.The bill prohibits prescription drug manufacturers or wholesale distributors permitted or licensed in the Commonwealth from accepting payment at an amount higher than the maximum fair price established by the U.S. Secretary of Health and Human Services pursuant to federal law for the sale of a referenced drug intended for use by individuals in the Commonwealth. Under the bill, an entity that violates such prohibition is subject to a civil penalty of $10,000 per violation. The bill also prohibits a manufacturer subject to its provisions from removing a referenced drug from sale distribution in the Commonwealth for the purpose of avoiding the impact of the bill's rate limitations without providing certain prior notice. Under the bill, a manufacturer that violates such prohibition on removing a referenced drug without the required notice is subject to a civil penalty equal to the greater of $100,000 or the total amount of annual savings for the referenced drug, as determined by the Board of Pharmacy. This bill is identical to HB 483.

Minor elementary or secondary school students admitted to inpatient treatment; certain disclosures to certain school personnel upon discharge. Provides that in the event that the facility to which a minor elementary or secondary school student is admitted to inpatient treatment determines that such minor student requires additional educational services upon discharge from the facility, the parents of such student may opt in to the disclosure, prior to or at the time of such minor student's discharge from the facility, of such determination by the facility to a mental health professional employed in such minor student's school or, if applicable, by the school division in which the student is enrolled. The bill also provides that, in the event that the facility to which a minor elementary or secondary school student is admitted to inpatient treatment determines, based on communications from such minor student to a mental health service provider at such facility, that the student poses a specific and immediate threat to cause serious bodily injury or death to an identified or readily identifiable person or persons at the time of the student's discharge from the facility, the facility shall disclose, prior to or at the time of discharge in accordance with the requirements set forth in relevant law, such determination to a mental health professional employed in such minor student's school or, if applicable, by the school division. The bill also prohibits any such facility from withholding discharge of such a student for the purpose of making any such disclosure. The provisions of the bill have a delayed effective date of January 1, 2027.

Bureau of Insurance; evaluation of All-Payer Claims Database; report. Directs the State Corporation Commission's Bureau of Insurance (the Bureau) to conduct an evaluation of the All-Payer Claims Database and the data submitted thereto in facilitating data-driven, evidence-based improvements in access, quality, and cost of health care in the Commonwealth. The bill requires the Bureau to submit a report of its findings and recommendations to the Governor and General Assembly no later than December 1, 2026.

Head Start State Collaboration Office; state of Head Start and Early Head Start in the Commonwealth; report. Requires the Head Start State Collaboration Office at the Department of Education, no later than December 1, 2026, to develop and recommend to the Commission on Early Childhood Care and Education for endorsement a report summarizing the state of Head Start and Early Head Start in the Commonwealth that is required to address several topics enumerated in the bill.

Prior authorization; requiring physician review for denial. Prohibits a health insurance carrier from making an adverse determination of a prior authorization request (i) for prescription drugs unless such denial has been reviewed and approved by a licensed physician or, if a licensed physician is not available, by a licensed pharmacist or (ii) for health care services unless such adverse determination has been reviewed and approved by (a) a licensed physician; (b) in the case of mental health services, a licensed mental health provider if a licensed physician is unavailable; or (c) in the case of dental services, a licensed dentist if a licensed physician is unavailable.

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.