Health insurance; required provisions regarding prior authorization for health care services.
HB2099 amends Virginia’s health insurance code to impose new prior authorization requirements on carriers for prescription drug benefits and for other health care services. For prescription drugs, the bill requires carriers to accept prior authorization requests electronically, telephonically, or by fax; respond within short timeframes; explain denials; maintain tracking systems; publish formularies, forms, and procedures in one central website location; and honor certain existing approvals across plan changes, carrier changes, dosage changes, and formulary changes. It also limits when an approved drug authorization may be revoked and creates special protections for medication-assisted treatment and certain mental health medications.
For non-drug health care services, the bill requires carriers to respond to expedited requests within 72 hours and standard requests within seven calendar days, to specify any needed supplementation, and to state reasons for denials. It also requires carriers to post prior authorization requirements, forms, effective dates, and annual prior authorization data online, and prohibits denial of claims when required posting rules were not followed. The bill further directs carriers and providers to support electronic prior authorization and real-time benefit information beginning July 1, 2025, and creates a work group to monitor federal developments and implementation readiness, with a report due by November 1, 2025.
The bill adds a new Code of Virginia section, 38.2-3407.15:8, and expands 38.2-3407.15:2 to strengthen prior authorization rules for prescription drugs. Its provisions apply to carrier-provider contracts entered into, amended, extended, or renewed on or after January 1, 2016, but the first enactment’s operative requirements take effect January 1, 2027. The measure also requires the Bureau of Insurance, with the Secretary of Health and Human Resources, to convene a stakeholder work group and report on implementation issues. It excludes several coverage types, including Medicare, Medicaid, CHIP, federal employee plans, TRICARE, workers’ compensation, dental and optometric plans, and certain HMOs meeting specified criteria.
The bill appears to have broad support and little visible opposition in the available record. It advanced unanimously through House and Senate committee stages and passed both chambers with 97-0 in the House and 40-0 in the Senate. The substitute versions and unanimous votes suggest the measure was refined in committee but remained generally well received across stakeholders and legislators.
The main policy tension is between improving patient access and transparency versus preserving carrier utilization-management tools and administrative flexibility. Carriers may be concerned about tight response deadlines, mandatory electronic systems, limits on revoking approvals, continuity-of-care requirements, and public posting obligations, while providers and patient advocates are likely to support those same provisions as reducing delays and treatment interruptions. The work group requirement indicates that implementation details, especially alignment with federal standards and readiness of industry systems, were still important enough to warrant further study.