HOUSE BILL NO. 1452

AMENDMENT IN THE NATURE OF A SUBSTITUTE

(Proposed by the House Committee on Health and Human Services

on ________________)

(Patron Prior to Substitute—Delegate Anthony)

A BILL to amend the Code of Virginia by adding a section numbered 32.1-325.1:2, relating to Department of Medical Assistance Services; expedited review process for Medicaid service authorization requests; report.

Be it enacted by the General Assembly of Virginia:

1. That the Code of Virginia is amended by adding a section numbered 32.1-325.1:2 as follows:

§ 32.1-325.1:2. Expedited review of certain Medicaid service authorization requests; authority; limitations.

A. The Department shall establish an expedited review process for Medicaid service authorization requests for items or services when use of the standard review timeframe could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum functioning consistent with applicable federal law.

B. Eligibility for expedited review pursuant to subsection A may be supported by certification of medical urgency from a physician or other licensed health care professional authorized under state or federal law to order or prescribe items or services eligible for expedited review pursuant to subsection A or by other documentation sufficient under federal law to demonstrate medical urgency.

C. Implementation of the expedited review process established pursuant to subsection A shall not be construed to:

1. Guarantee approval of any request under review;

2. Create a new entitlement to coverage or payment;

3. Expand the scope of Medicaid benefits;

4. Alter existing medical necessity criteria;

5. Create a private cause of action; or

6. Require the Department to:

a. Accept incomplete or insufficient documentation required pursuant to subsection B;

b. Conduct new data collection, medical testing, or environmental monitoring;

c. Obtain or provide medical equipment; or

d. Engage consultants for implementation of this section.

D. The Department shall implement the expedited review process established pursuant to subsection A and may submit state plan amendments, apply for waivers, issue or amend guidance documents and provider manuals, and adopt or amend regulations as may be necessary to carry out the provisions of this section and to secure federal financial participation for state Medicaid expenditures under the federal Medicaid program. The expedited review process established pursuant to subsection A shall be implemented to the extent consistent with federal law and subject to securing any necessary federal approvals and federal financial participation.

E. The Department shall report annually by November 1 to the House Committee on Appropriations, the Senate Committee on Finance and Appropriations, the House Committee on Health and Human Services, and the Senate Committee on Education and Health on the implementation of the expedited service authorization review process established pursuant to subsection A. Such report shall include:

1. The number of requests subject to expedited review;

2. Data on the timeframes for responding to requests;

3. The number of approvals and denials of requests reported in the aggregate;

4. Any barriers to implementation; and

5. Recommendations for improvement of the process.

2. That if the Department of Medical Assistance Services does not receive the necessary approval or federal financial participation from the Centers for Medicare and Medicaid Services to implement the provisions of this act, then the provisions of this act shall expire on July 1, 2027.