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 implement expedited review of Medicaid service authorization requests consistent with applicable federal law and regulations governing expedited prior authorization determinations.

B. Nothing in this section shall be construed to diminish or alter existing federal or state requirements regarding documentation or certification necessary 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 annually transmit the prior authorization report required by the Centers for Medicare and Medicaid Services and publicly posted by the Department to the Chairs of the House Committees on Appropriations and Health and Human Services and the Senate Committees on Finance and Appropriations and Education and Health within 30 days of such public posting. The Department may include additional summary information related to expedited service authorization determinations, including, to the extent available from existing data systems and collected in the ordinary course of business, the number of requests initially processed as standard that were subsequently determined to meet the criteria necessary for expedited service authorization.