VA SB 1261

Title: Health insurance; electronic prior authorization and disclosure of certain information.
Author: Siobhan Stolle Dunnavant

Summary
Health insurance; electronic prior authorization and disclosure of certain prescription drug information. Requires each health insurance carrier, beginning July 1, 2025, to establish and maintain an online process that (i) links directly to all e-prescribing systems and electronic health record systems that utilize the National Council for Prescription Drug Programs SCRIPT standard; (ii) can accept electronic prior authorization requests from a provider; (iii) can approve electronic prior authorization requests (a) for which no additional information is needed by the carrier to process the prior authorization request, (b) for which no clinical review is required, and (c) that meet the carrier's criteria for approval; (iv) links directly to real-time patient out-of-pocket costs for the encounter; and (v) otherwise meets the requirements for contracts between carriers and participating health care providers. The bill prohibits a carrier from (a) imposing a fee or charge on any person for accessing the required online process who is required to do so or (b) accessing, absent provider consent, provider data via the online process other than for the enrollee. The bill also requires carriers, no later than July 1, 2024, to provide contact information of any third-party vendor or other entity the carrier will use to meet the requirements of the bill to any provider that requests such information. The carrier may post such information on its website to meet such requirement. The bill requires participating health care providers, beginning July 1, 2025, to ensure that any e-prescribing system or electronic health record system owned by or contracted for the provider to maintain an enrollee's health record has the ability to access the electronic prior authorization process established by a carrier and real-time cost information data for a covered prescription drug made available by a carrier. The bill provides that a provider may request a waiver of compliance for undue hardship for a period not to exceed 12 months. The bill requires any carrier or its pharmacy benefits manager to provide real-time cost information data to enrollees and contracted providers for a covered prescription drug, including any cost-sharing requirement or prior authorization requirements, and to ensure that the data is accurate. The bill requires that such cost information data be available to the provider in an accessible and understandable format, such as through the provider's e-prescribing system or electronic health record system that the carrier or pharmacy benefits manager or its designated subcontractor has adopted that utilizes the National Council for Prescription Drug Programs SCRIPT standard from which the provider makes the request. The bill requires the State Corporation Commission's Bureau of Insurance to, in coordination with the Secretary of Health and Human Resources and subject to the availability of nongeneral funds appropriated to the Commission, establish a work group to assess implementation and develop recommendations for electronic prior authorization and real-time cost benefit information for prescription drugs. The work group shall report its findings and recommendations to the Chairmen of the Senate Committees on Commerce and Labor and Education and Health and the House Committees on Commerce and Energy and Health, Welfare and Institutions annually by November 1 and shall make its final report by November 1, 2025.

Status
Senate: Bill text as passed Senate and House (SB1261ER)

Bill Documents
VA SB 1261 - Senate amendments not adopted

VA SB 1261 - House amendments engrossed

VA SB 1261 - House amendments adopted

VA SB 1261 - Committee substitute printed 23105922D-S1

VA SB 1261 - Substitute for S-Finance and Appropriations Offered on 1/31/2023

VA SB 1261 - Amendment(s) for S-Commerce and Labor Offered on 1/23/2023

VA SB 1261 - Bill text as passed Senate and House (SB1261ER)

VA SB 1261 - Prefiled and ordered printed; offered 01/11/23 23103745D

VA SB 1261 - Senate amendments

VA SB 1261 - Senate committee, floor amendments and substitutes offered

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VA SB 1261