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An Act to amend and reenact §§
38.2-3407.15:5
and
38.2-3418.10
of the Code of Virginia, relating to health insurance; cost-sharing payments for insulin and diabetes equipment and supplies; limit.
Be it enacted by the General Assembly of Virginia:
1. That §§
38.2-3407.15:5
and
38.2-3418.10
of the Code of Virginia are amended and reenacted as follows:
§
38.2-3407.15:5
. Limit on cost-sharing payments for prescription insulin drugs.
A. As used in this section:
"Carrier" has the same meaning ascribed thereto in subsection A of §
38.2-3407.15
.
"Cost-sharing payment" means the total amount a covered person is required to pay at the point of sale in order to receive a prescription drug that is covered under the covered person's health plan.
"Covered person" means a policyholder, subscriber, participant, or other individual covered by a health plan.
"Health plan" means any health benefit plan, as defined in §
38.2-3438
, that provides coverage for a prescription insulin drug.
"Pharmacy benefits manager" means an entity that engages in the administration or management of prescription drug benefits provided by a carrier for the benefit of its covered persons.
"Prescription insulin drug" means a prescription drug that contains insulin and is used to treat diabetes.
"Provider contract" has the same meaning ascribed thereto in subsection A of §
38.2-3407.15
.
B. Every health plan offered by a carrier shall set the cost-sharing payment that a covered person is required to pay for a covered prescription insulin drug at an amount that does not exceed
$50
$35 in aggregate, including situations where the covered person is prescribed more than one insulin drug,
per 30-day supply of the prescription insulin drug, regardless of the amount or type of insulin needed to fill the covered person's prescription.
C. Nothing in this section shall prevent a carrier from setting a covered person's cost-sharing payment for a covered prescription insulin drug at an amount that is less than the maximum amount permitted pursuant to subsection B.
D. No provider contract between a carrier or its pharmacy benefits manager and a pharmacy or its contracting agent shall contain a provision (i) authorizing the carrier's pharmacy benefits manager or the pharmacy to charge, (ii) requiring the pharmacy to collect, or (iii) requiring a covered person to make a cost-sharing payment for a covered prescription insulin drug in an amount that exceeds the amount of the cost-sharing payment for the covered prescription insulin drug established by the carrier pursuant to subsection B.
E. This section shall apply with respect to health plans and provider contracts entered into, amended, extended, or renewed on or after January 1, 2021.
F. Pursuant to the authority granted by §
38.2-223
, the Commission may adopt such rules and regulations as it may deem necessary to implement this section.
§
38.2-3418.10
. Coverage for diabetes.
A.
As used in this section:
"Cost-sharing payment" means the total amount a covered person is required to pay at the point of sale in order to receive equipment and supplies that are covered under the covered person's policy, contract, or plan.
"Equipment and supplies" means blood glucose meters and strips, urine-testing strips, syringes, continuous glucose monitors and supplies, and insulin pump supplies. "Equipment and supplies" shall not be considered durable medical equipment.
B.
Each insurer proposing to issue an individual or group hospital policy or major medical policy in this Commonwealth, each corporation proposing to issue an individual or group hospital, medical or major medical subscription contract, and each health maintenance organization providing a health care plan for health care services shall provide coverage for diabetes as provided in this section.
B.
C.
Such coverage shall include benefits for equipment
,
and
supplies and in-person outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes
,
and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law.
As used herein, the terms "equipment" and "supplies" shall not be considered durable medical equipment.
C.
D.
To qualify for coverage under this section, diabetes in-person outpatient self-management training and education shall be provided by a certified, registered or licensed health care professional. A managed care health insurance plan, as defined in Chapter 58 (§
38.2-5800
et seq.) of this title, may require such health care professional to be a member of the plan's provider network; provided that such network includes sufficient health care professionals who are qualified by specific education, experience, and credentials to provide the covered benefits described in this section.
D.
E.
No insurer, corporation, or health maintenance organization shall impose upon any person receiving benefits pursuant to this section any copayment, fee
,
or condition that is not equally imposed upon all individuals in the same benefit category, nor shall any insurer, corporation
,
or health maintenance organization impose any policy-year or calendar-year dollar or durational benefit limitations or maximums for benefits or services provided under this section.
Additionally, every policy, contract, or plan offered by an insurer, corporation, or health maintenance organization shall set the cost-sharing payment that a covered person is required to pay for equipment and supplies at an amount that does not exceed $35 in aggregate, including situations where the covered person is prescribed more than one piece of equipment or type of supplies, per 30-day supply of the equipment and supplies, regardless of the amount or type of equipment or supplies needed to fill the covered person's prescription.
E.
F.
The requirements of this section shall apply to all insurance policies, contracts and plans delivered, issued for delivery, reissued, or extended on and after July 1, 2000, or at any time thereafter when any term of the policy, contract or plan is changed or any premium adjustment is made.
F.
G.
This section shall not apply to short-term travel, accident only, or limited or specified disease policies or contracts, nor to policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans.
2. That the provisions of this act shall apply to insurance policies, contracts, and plans delivered, issued for delivery, reissued, amended, or extended on or after January 1, 2027.
3. That, to the extent that the health benefit for diabetes equipment and supplies or any portion thereof described in §
38.2-3418.10
of the Code of Virginia, as amended by this act, is included in the Commonwealth's current essential health benefits benchmark plan, as defined in §
30-343.1
of the Code of Virginia, the mandate to provide coverage of such benefit or portion shall not apply to the individual and small group markets. However, the provisions of this enactment clause shall not apply to subdivision E of §
38.2-3418.10
of the Code of Virginia, as amended by this act.