AT A GLANCE

This bill requires the Health Care Commission, with the Primary Care Reform Collaborative, to monitor value-based primary care uptake and approve a Delaware Primary Care Model with specified quality and social-disparities targets.

FULL SUMMARY

The bill establishes and extends Delaware’s primary care value-based payment and cost-containment framework across commercial insurance (Title 18) and state/group public insurance arrangements (Titles 29 and 31), centering implementation around the Office of Value-Based Health Care Delivery (OVBHCD) and the Health Care Commission/Primary Care Reform Collaborative (PCRC).

It makes several targeted statutory changes. First, Title 16, § 9903 requires the Health Care Commission, in coordination with the Primary Care Reform Collaborative, to monitor uptake and compliance of primary care providers with value-based delivery models and to advise/approve a Delaware Primary Care Model with specified targets (alternative payment models tied to quality/performance) and a social determinants/disparities focus. Second, Title 16, § 9904A changes reporting authority by removing the prior time-frame limitation on when the Commission may require written insurer reporting on progress in adopting/implementing value-based payment models.

Third, Title 18, § 329 expands how administrative penalties work by allowing penalties for specified violations (including related to rate-making and primary care coverage requirements) to be equivalent to the monetary value of the relevant violation, and by directing that such penalties be deposited into a newly referenced “Primary Care Fund,” used by the Statewide Benefits Office and the Division of Medicaid and Medical Assistance for implementation/support functions related to group/public primary care coverage requirements. Fourth, Title 18, § 334 strengthens OVBHCD’s regulatory authority by requiring (through regulation) mandatory payment minimums for specified “payment innovations” to support primary care by January 1, 2026; directing data collection and development of standardized primary-care performance measures; establishing value-based care program designs to increase accountability and improve access; and requiring regulations (by January 1, 2029) establishing limits on covered persons’ financial responsibility for covered services.

Fifth, the bill updates cost-containment and primary care spending/payment rules for both commercial and public programs. Title 18, § 2503 shifts rate-filing cost caps (for non-exempt services) from a fixed percentage-of-Medicare formulation toward “Medicare Reference-Based Pricing Targets” expressed as percentages of a “Full Medicare rate,” with distinct targets for inpatient hospital, outpatient, and emergency department services, and additional Medicare/RBP references for free-standing children’s hospitals; it also adds structured exemptions (e.g., Medicare-Dependent Rural Hospitals, Urban Medicaid DSH Hospitals, and approved global budget or qualifying multi-payer/value-based arrangements) with department notice requirements and additional requirements for qualifying value-based arrangements (scope, payment share ≥40% of gross health system revenue, downside risk, departmental certification). Separately, Title 18, §§ 3342B and 3556A require carriers to spend at least 11.5% of total medical cost on primary care beginning in 2026, with at least 5% through prospective primary care management payments; carriers must offer Department-issued program-design-element value-based care and may not deny provider participation if providers accept uniform program terms. For public coverage, Titles 29 and 31 add/report and annual step-up requirements: plans/entities must report primary-care-spend percentage data for specific plan years and then increase primary care spending by 1% each year until reaching 11.5% of total medical costs thereafter. The bill also deletes a sunset/repeal clause that would have expired key provisions effective January 1, 2027, and requires the Department of Insurance to promulgate implementing regulations within 18 months of enactment.

AT A GLANCE

This bill requires insurers and state public-coverage carriers to spend at least 11.5% of total medical care on primary care starting in 2026, including at least 5% through prospective primary care management payments.

FULL SUMMARY

The bill establishes and expands Delaware’s primary-care value-based health-care requirements across the Health Care Commission/Primary Care Reform Collaborative (Title 16), the Office of Value-Based Health Care Delivery (Title 18), and the State Group Health Insurance Plan and state public assistance health coverage (Titles 29 and 31). It also modifies cost-containment mechanisms tied to primary-care spending and sets new reporting and regulatory directions for commissioners and insurers. Key themes include: ongoing monitoring of provider participation in value-based models, stronger and more permanent primary-care spending commitments by carriers, and a shift (starting in later rate years) toward Medicare “Reference-Based Pricing Targets” for hospital-related services.

The bill changes the Health Care Commission’s duties by requiring coordination with the Primary Care Reform Collaborative to monitor primary-care provider uptake/compliance with value-based care delivery models, including advising and approving a Delaware Primary Care Model. It also removes a restriction that previously limited the period for the Collaborative’s authority to request insurer reports, allowing continued requests going forward. For enforcement, it creates a Primary Care Fund for certain administrative penalties and specifies that penalties for specified violations may be set equivalent to the monetary value associated with the violation; those funds are to be used by the Statewide Benefits Office and the Division of Medicaid and Medical Assistance to implement/support statutory primary-care provisions.

For insurance rate regulation and cost containment, the bill modifies the statutory rate-making limits in Title 18 to extend and reshape constraints on hospital-related costs. It extends cost containment calculations through the 2027 rate filing year and, for rate filings in and after 2028, limits costs per inpatient hospital service, outpatient service, and emergency department service based on Medicare Reference-Based Pricing Targets tied to the “Full Medicare rate,” the Free-Standing Children’s Hospital Medicare outpatient payment rate, or the TEFRA Rate—depending on service type and provider type (Free-Standing Children’s Hospital versus other hospitals). It retains and clarifies exemptions from these targets for specified hospitals (e.g., Medicare-Dependent Rural Hospitals, Urban Medicaid DSH hospitals, and hospitals participating in approved global budget models) and adds that certain smaller facilities and other qualified hospitals are exempt from specified extensions. It also modifies commercial-market carrier rate filing requirements by requiring progress toward value-based care/alternative payment model participation for carriers with sufficient membership size across consecutive years.

The bill strengthens primary-care spending and program participation requirements for carriers in both the commercial market (Title 18, §3342B and §3556A) and public coverage programs (Title 29, §5204 and Title 31, with new §539). Starting in 2026 and each year thereafter, carriers must spend at least 11.5% of total medical care on primary care, with at least 5% provided via prospective primary care management payments; carriers must offer value-based care programs meeting Department-issued program design element requirements and may not deny contracted provider participation if the provider accepts standard program terms. It also directs the Commissioner/Division to develop regulations/methodology for calculating total cost of care and primary-care compliance. For state public coverage: (1) the Group Health Insurance Plan (Title 29) is tied to the same Medicare Reference-Based Pricing Target limits for plan years 2030+ and requires reporting to the Office of Value-Based Health Care Delivery for primary-care spending percentages for plan years 2027 and 2028, with 1% annual increases thereafter until 11.5% is reached; and (2) the bill creates a new Title 31 §539 obligation for entities providing health insurance under §505(3) to report for two plan years and then increase primary-care spending by 1% per year until it reaches 11.5%, and to offer value-based care programs as determined by contract with the Division. Finally, it provides that the Department of Insurance must promulgate regulations within 18 months of enactment, and by January 1, 2027 must establish a methodology for appropriate annual inflationary/other adjustments to a hospital’s Full Medicare Rate.

AT A GLANCE

This bill prohibits providers from charging, billing, or collecting facility fees except for services on a hospital campus, at facilities with licensed emergency departments, or for specified emergency services.

FULL SUMMARY

The bill creates new Massachusetts requirements to limit “facility fees” and to protect insureds from “surprise billing,” primarily by adding new sections to Chapter 111 (health care provider/facility fee rules), updating a notice-and-billing restriction in Chapter 111 for non-emergency out-of-network services, revising definitions and enforcement/payment rules in Chapter 175H, and adding carrier reimbursement and out-of-network surprise-billing standards in Chapters 176J and 176O.

For facility fees, Chapter 111 is expanded by inserting new Sections 51P and 51Q. Section 51P defines key terms including “campus” (hospital buildings and adjacent areas within specified geographic parameters), “facility fee” (separate hospital/health-system operational charges distinct from professional fees), “hospital,” and “professional fee.” It prohibits a health care provider from charging, billing, or collecting facility fees except for specified settings: services on a hospital’s campus, services at a facility with a licensed hospital emergency department, or emergency services at a licensed satellite emergency facility. It also requires the Department of Public Health to promulgate regulations and provide penalties for noncompliance (fine up to $1,000 per occurrence) and allows the Department to identify services that may reliably be provided safely/effectively outside hospital settings, for which facility fees may not be charged. Section 51Q requires notice to patients when facility fees are charged/billed/collected, including timing rules (e.g., if appointments are scheduled at least 10 days out, notice/explanation must be sent at least 3 days after scheduling by specified methods; otherwise notice must be given on premises or prior to care where practicable). It also requires facility identification as being associated with a hospital and requires posted notice that patients may incur higher liability than at non-hospital facilities. If a location’s status changes such that facility fees become permissible, Section 51Q requires notice to prior patients within a set period and bars charging facility fees until at least 30 days after the required written notice is provided; notices must be filed with the department within set timelines. It further provides that violations constitute an unfair trade practice under Chapter 93A and can be subject to Department-imposed penalties.

The bill also amends existing surprise/out-of-network billing rules. In Chapter 111, it revises Section 228(e) (as appearing in the 2022 Official Edition) by striking the prior subsection (e) and inserting a new version that requires participating status determination and patient notification for non-emergency services: if the provider does not participate in the patient’s health benefit plan and the service is scheduled more than 7 days in advance, written and verbal notice must be given at least 7 days prior; if scheduled less than 7 days in advance, verbal notice must be given at least 2 days prior (or as soon as practicable) with written notice upon the patient’s arrival. If the provider fails to provide required notifications, or if the provider renders unforeseen out-of-network services, the provider may not bill the insured except for applicable copayment/coinsurance/deductible that would apply if the insured received the service from a participating provider. The bill clarifies that this does not remove the provider’s continuing obligations under other subsections of Section 228(b)–(d).

In related insurance enforcement and reimbursement provisions, the bill adds definitions to Chapter 175H: “impermissible facility fee” (a facility fee not charged in accordance with Chapter 111’s new facility fee requirements) and “surprise bill” (bills received by an insured for unforeseen out-of-network services). It replaces Chapter 175H Sections 5 and 6 with updated enforcement language: it authorizes the Attorney General to investigate alleged violations, commence proceedings, and bring civil actions; and it requires notifying relevant licensing authorities when violations are determined, allowing those authorities to impose penalties. The bill also inserts a new civil-liability rule in Section 6 that holds knowing fraudulent claim submitters/recipients liable for full benefits/payments plus attorneys’ fees/costs, including investigation costs, with a civil action available in superior court. It adds new Section 6A prohibiting forwarding of a “surprise bill” to a person covered by an insured health plan, imposing penalties and attorneys’ fees/costs and authorizing civil actions.

Finally, the bill updates carrier reimbursement and surprise-billing standards. In Chapter 176J, it adds Section 18 requiring carriers to reimburse evaluation and management services delivered by specified off-campus hospital outpatient departments/clinics/ambulatory surgical centers/stand-alone emergency departments and certain ambulatory services (including lab tests, imaging/diagnostics, and identified clinician-administered drugs) at an equivalent rate to the Medicare physician fee schedule non-facility rate applicable to physician offices. In Chapter 176O, it adds Section 31 establishing “unforeseen out-of-network service” categories (emergency and defined non-emergency scenarios, including services rendered by specific specialty types, cases without advanced knowledge, no in-network provider available at the facility, referred-out situations such as off-network laboratory/radiologist/pathologist, and unforeseen services that must necessarily be rendered by an out-of-network provider; plus ambulance services). It limits insured cost-sharing to in-plan applicable coinsurance/copayment/deductible/out-of-pocket amounts as if rendered by a participating provider, and requires the carrier to reimburse the out-of-network provider at the carrier’s median contracted rate for the service in the geographic region/market, treating that payment as payment-in-full and prohibiting additional billing to the insured except for applicable in-network cost sharing. For certain self-funded plans under ERISA, coverage under the section applies only if the plan elects in the manner prescribed (annual notice to the division and plan-document amendments). Section 31 also includes coverage/charge limits tied to legal and plan terms and an insured-consent opportunity concept for nonemergency services, including possible reliance on a signed consent waiver; the commissioner must promulgate regulations to implement the section.

AT A GLANCE

This bill requires health plans, contracts, and Medicaid providers to reimburse contracted CRNAs for anesthesia services at least as much as contracted physicians for the same service.

FULL SUMMARY

The bill establishes requirements across multiple Massachusetts health insurance and managed care contexts to treat physicians and certified registered nurse anesthetists (CRNAs) equivalently for anesthesia services when the practitioner is acting within the scope of practice under their licensure/certification. It also requires claims to identify the National Provider Identifier (NPI) of the physician or CRNA who provided the service, and it authorizes health plans/carriers to vary reimbursement only based on quality or performance measures that are the same for physicians and CRNAs.

It amends state law by adding a new patient-care reimbursement parity section to the Commonwealth’s group health coverage framework (Chapter 32A), and by adding parallel parity and payment-floor rules to Medicaid-related provisions (Chapter 118E), individual and group accident/sickness insurance statutes (Chapter 175), and hospital service plan contract requirements (Chapter 176A). For each of these settings, a contracted CRNA must be reimbursed in an amount not less than the allowed amount payable for the same service when provided by a contracted physician, and the carrier/plan may not reduce physician reimbursement to comply.

The bill also makes definitional and structural changes in insurance statutes governing medical service corporations (Chapter 176B) and health maintenance organizations (Chapter 176G): it adds definitions for “certified registered nurse anesthetist” and “participating certified registered nurse anesthetist,” adjusts the “medical service” definition to include CRNAs, and strikes out “certified registered nurse anesthetist or” wherever it appears in Section 4T. In addition, it adds new contract parity provisions for medical service corporation subscriber contracts and health maintenance organization member contracts, including the same NPI identification requirement and the CRNA reimbursement non-underpayment / no-physician-reduction protections.

Finally, it adds analogous requirements for other insurance arrangements covering anesthesia services, including preferred provider contracts and preferred provider arrangements (Chapter 176I), and it provides that when another law or rule requires physician authorization/involvement as a condition of reimbursement or coverage of anesthesia services, the requirement may be satisfied by a CRNA practicing in an advanced practice role under Chapter 112, Section 80B. The commissioner of insurance must promulgate rules and regulations to implement and enforce the act.

AT A GLANCE

This bill requires Medi-Cal to reimburse advanced practice pharmacist MTM services at least 85% of the physician fee schedule and requires DHCS to implement an MTM methodology limiting payments to eligible providers.

FULL SUMMARY

The bill requires that, under Medi-Cal, the reimbursement rate for advanced practice pharmacist services be no less than 85% of the Medi-Cal physician fee schedule, expressly including medication therapy management (MTM) pharmacist services (Health and Safety Code and Welfare & Institutions Code reimbursement provisions). It also requires the Department of Health Care Services (DHCS) to implement an MTM reimbursement methodology that limits Medi-Cal payments for MTM pharmacist services (provided in conjunction with certain specialty drug therapy categories) to eligible advanced practice pharmacists or pharmacies, including those operating at federally qualified health centers (FQHCs) and rural health clinics.

For commercial payers, the bill expands pharmacist-coverage payment/reimbursement rules by requiring health care service plans and disability insurers to pay or reimburse pharmacist services not only when the pharmacist is at an in-network or out-of-network pharmacy (as already provided), but also when the pharmacist is enrolled as a provider with the plan or insurer. It specifies that “pharmacist” includes pharmacists providing services at FQHCs or rural health clinics, and requires that any payment/reimbursement may be made only when the service is within the lawful scope of practice and the coverage otherwise reimburses similar services performed by other licensed health care providers.

To support Medi-Cal MTM implementation, the bill amends the MTM statute to clarify that MTM reimbursement is intended to ensure Medi-Cal payments are made only to eligible advanced practice pharmacists or pharmacies (including FQHCs and rural health clinics) for MTM services tied to covered specialty drug therapy categories identified by DHCS. It requires DHCS to seek necessary federal approvals and to implement only to the extent federal financial participation is available, while also allowing DHCS to implement MTM through nonregulatory communications (e.g., provider bulletins) and maintaining protocols/utilization controls, eligibility criteria, and specialty-drug-category lists.

The bill applies MTM reimbursement to dates of service on or after July 1, 2021, or the later effective date reflected in necessary federal approvals, whichever is later, and includes a statutory state-mandated local program/no-reimbursement provision under specified constitutional criteria tied to whether the bill creates, eliminates, or changes a crime/infraction or penalty.

AT A GLANCE

This bill prohibits payors from including in physician participation contracts any clause that restricts or penalizes a physician practice’s ability to charge reasonable administrative or operational fees to patients.

FULL SUMMARY

The bill establishes a new set of rules within Title 5 (Businesses and Professions) called the “Primary Care Preservation Act” (new Chapter 37.9). It defines key terms including “administrative or operational fee,” “payor,” and “physician practice,” and then regulates how payors may contract with physician practices regarding the practice’s ability to charge patients reasonable non-clinical administrative/operational fees.

It prohibits payors from including in any physician participation contract, agreement, or participation document any clause that prohibits, restricts, penalizes, or interferes with the physician practice’s ability to charge, bill, or collect a reasonable administrative or operational fee directly from patients (Section 5-37.9-3(a)). It also prohibits payors from imposing conditions, penalties, or sanctions on physician practices for assessing such fees, as long as the fees are disclosed to patients in advance and are not billed to the payor (Section 5-37.9-3(b)). The bill clarifies that it does not require payors to reimburse physician practices or patients for these fees (Section 5-37.9-3(c)).

It preserves physician practice obligations related to patient access and continuity of care by stating that nothing in the chapter limits a practice’s obligation to provide emergency or urgent care regardless of whether the practice charges an administrative or operational fee (Section 5-37.9-4(a)). It requires physician practices to provide reasonable notice and access to patient medical records consistent with state and federal law (Section 5-37.9-4(b)).

For enforcement, any payor contract provision that violates the chapter is declared null and void and unenforceable as a matter of public policy (Section 5-37.9-5). The bill includes a severability clause (Section 5-37.9-6) and sets an effective date of “upon passage” (Section 2).

AT A GLANCE

This bill requires health care providers to obtain separate, signed informed consent for payment using a uniform patient liability consent form, and it prohibits unenforceable noncompliant forms.

FULL SUMMARY

The bill establishes that informed consent to provide health care services must be obtained separately from consent to pay for those services, but it removes the prior requirement that consent to pay may not be given until after the patient receives the services. Instead, it requires that any consent for payment use a uniform patient liability consent form developed by the Superintendent of Financial Services in conjunction with the Commissioner.

The bill amends Public Health Law § 18-c to require the uniform consent/payment form to (1) exclude any language requiring patients to assume unlimited financial liability, (2) state that the patient is liable only for the cost of services actually provided, and (3) include specified “understand” language reflected in the statute’s inserted text. It also specifies that the form must include procedures related to providing patients a “good faith estimate” of current or future visits or procedures upon request, subject to regulations developed by the Superintendent of Financial Services in conjunction with the Commissioner.

The bill further provides that the consent-for-payment form must be signed by the patient or their legal representative; any form that does not comply with the section is prohibited and unenforceable. For purposes of the statute, “consent” is defined as an affirmative action that clearly and conspicuously communicates authorization; is made without interface mechanisms designed to obscure/subvert/impair decision-making or choice; and cannot be inferred from inaction.

The act takes effect immediately.

AT A GLANCE

This bill requires Missouri to implement expanded public health reporting and disease-program requirements, including Lyme disease and alpha-gal syndrome electronic lab reporting and related follow-up.

FULL SUMMARY

The bill repeals numerous existing Missouri health-care related statutory sections and replaces them with “eighty new sections relating to health care, with penalty provisions,” including new sections on health awareness designations, health-care provider practice requirements, public health reporting and disease programs, health benefit/coverage requirements, professional licensure/discipline changes, and specified criminal/civil penalty and reporting provisions.

Operatively, the bill (1) creates or redesignates multiple public health “awareness” designations in Missouri (weeks/months/days) and (2) substantially restructures several health and health-system legal frameworks by establishing new statutory sections covering, among other topics, Lyme disease surveillance/eradication (including reporting duties, a dedicated “Lyme Research and Eradication Fund,” a Lyme task force, and protections against license discipline solely for within-scope Lyme-related treatment), alpha-gal syndrome reporting and follow-up (including electronic lab reporting and annual CDC reporting), and a Pregnancy-Associated Mortality Review Board with defined membership, review duties, confidentiality protections, and data sharing/reporting requirements.

In health-care delivery and provider regulation, the bill changes rules governing (a) school-related medication and epinephrine delivery (including training/authorization, emergency use, and immunity/first-aid treatment treatment standards), (b) telemedicine requirements for establishing a physician-patient relationship and evaluation duties (including evaluation/record-keeping and limits on questionnaire-only relationships without required evaluation), and (c) standing orders and clinical standing orders for certain non-controlled uses (e.g., prenatal vitamins and doula recommendations), including immunities. It also updates health-system and payer operational requirements in several areas, including (i) limitations on hospital collection actions for periods of hospital price transparency noncompliance, (ii) MO HealthNet/Medicaid program policy mechanisms including doula coverage requirements and “Food is Medicine” provisions, (iii) show-me healthy babies unborn child coverage, and (iv) additional health benefit insurance coverage requirements for specified items (e.g., home blood pressure monitoring devices for pregnant/postpartum persons and anesthesia-payment rules prohibiting certain payment time limits).

The bill also implements system-level administrative process requirements, including expanded prior-authorization technology and reporting obligations for utilization review entities and health carriers (notably API-based submission/response and online processes for prescription and non-prescription prior authorizations, plus published statistics and reporting on approvals/denials and timeliness), and contains multiple compliance/fee/penalty features across drug and professional regulation. Examples include (i) changes to ephedrine/pseudoephedrine/phenylpropanolamine quantity limits and tracking-fee administration, with corresponding updates to criminal penalty triggers in methamphetamine precursor offenses, and (ii) establishment/adjustment of funds and confidentiality rules tied to public safety and health data. Finally, the bill includes statutory changes affecting mental health detention/evaluation procedures (including notarization and filing allowances), and contains a provision addressing limits on the establishment/operation of Missouri state-based or federally facilitated health benefit exchanges without specified statutory authority.

AT A GLANCE

This bill authorizes the Commissioner to enforce out-of-network carrier payment requirements by ordering corrective payments and fines when underpayment is identified and requiring compliant remittance transparency.

FULL SUMMARY

The bill changes Colorado’s out-of-network health-care dispute-related provisions in CRS 10-16-704 to modify how the state division enforces carrier payment requirements and how carriers provide payment and related transparency information to providers.

The bill updates CRS 10-16-704(13) by directing the General Assembly’s stated intent for subsection (13): (1) streamline out-of-network dispute resolution by granting the Division additional enforcement authority within the out-of-network complaint process, including requiring prompt payment by carriers when underpayment is identified; (2) require “jurisdictional transparency” by mandating that carriers clearly state on a remittance advice when a patient’s health benefit plan is governed by state law; and (3) empower data-driven enforcement by requiring carriers to disclose specific methodologies used to determine out-of-network reimbursement and by granting the Commissioner authority to order corrective payments and impose fines for noncompliance.

Operationally, when a carrier makes a payment pursuant to specified provisions of the section, providers may request—and the Commissioner must collect—data from the carrier to evaluate compliance in paying the highest rate required, including the methodology used to determine the carrier’s median in-network rate and corresponding reimbursement for each service in the same geographic area. The data submitted are characterized as proprietary/traet secret/confidential under the referenced confidentiality statute. In addition, beginning January 1, 2027, when making such payments, the carrier must provide a remittance advice identifying when the health benefit plan is regulated by state law and that the payment was made pursuant to the specified subsections. The bill also requires that each remittance advice include the carrier’s median in-network reimbursement rate for out-of-network claims.

The act becomes effective after the statutory referendum-petition period, specifically at 12:01 a.m. on the day following expiration of the 90-day period after final adjournment (August 12, 2026 if adjournment sine die is May 13, 2026), unless a referendum petition is filed and the act is approved by voters in November 2026; if approved, it takes effect upon official declaration of the vote by the governor. It applies to payments owed by health insurance carriers on or after the applicable effective date.

AT A GLANCE

This bill imposes a FY 2026–2027 annual assessment on covered hospitals equal to 6% of the total federally recognized annual coverage assessment base, after CMS permits the directed-payment structure.

FULL SUMMARY

The bill establishes the “Annual Coverage Assessment Act of 2026” within Tennessee Code Annotated (Title 71, Chapter 5, Part 20) and sets out how an annual assessment is imposed on “covered hospitals” for FY 2026–2027. It defines key terms, including how each hospital’s “annual coverage assessment base” is calculated primarily from 2021 Medicare cost report data (with multiple adjustment rules for hospitals with incomplete/absent 2021 cost reports, newly licensed hospitals, and replacements), and it defines which hospitals are “excluded.” It also requires that the assessment is not effective until TennCare/TennCare’s division provides written notice to the Tennessee Hospital Association that CMS has determined the assessment is permissible and not harmful to federal financial participation and has approved the related directed-payment structure or, alternatively, the division’s directed payment rules.

For FY 2026–2027, the bill imposes an aggregate annual assessment equal to 6% of the total federally recognized annual coverage assessment base and prescribes how each hospital’s assessment is weighted based on its classification (children’s, tier 1–3, psychiatric, safety net, and high out-of-state medicaid) using specific inpatient/outpatient weight factors derived from 2023 joint annual report data. It also requires installment payment scheduling: assessment installments are due fifteen days after CMS-approved FY 2026–2027 directed payments are made to hospitals, with the division providing notices and return forms at least 30 days in advance. Late payment triggers a $500/day penalty until paid; the division may waive the penalty if the hospital shows an attempted timely payment.

The bill places conditions on how the assessment proceeds may be used and limits impacts on managed care rates: it directs that assessment proceeds are not to be used to justify across-the-board rate reductions in existing negotiated rates as of July 1, 2026, while allowing case-by-case good faith negotiations and allowing rate changes when mandated by CMS or state/federal law or when the assessment becomes invalid. It requires the “maintenance of coverage trust fund” to hold assessment revenues, penalties, and specified intergovernmental transfers (up to $300 million), and it specifies covered uses for monies in that trust fund, including categories of expenditures and multiple enumerated dollar amounts (e.g., graduate medical education maintenance at at least $48 million; multiple offsets and initiatives including specified amounts for children’s emergency care rate maintenance and other targeted programs). The bill also provides a CMS-approval failure mechanism: if CMS does not approve the assessment as a valid revenue source, or if directed payments are reduced or assessment requirements are not fully satisfied, the division must suspend due installments and further payments, and—if applicable—must adopt emergency rules to establish alternative payment methodology, prioritization, benefits identification, and timing.

The bill creates enforcement and accountability provisions: it authorizes civil actions by the division to collect delinquent assessments/penalties/refunds with exclusive jurisdiction and venue in Davidson County chancery court; it defines consequences for failure to pay (including payment suspension tied to a directed payments provision and treating nonpayment/refund failure as a license deficiency grounds for discipline); it provides a declaratory order petition right for a covered-hospital association (if it represents 30+ covered hospitals) and prohibits surcharge/charge increases based on the assessment. It also sets the part’s duration and wind-down: the part expires July 1, 2027, but late-payment collection authority, declaratory order rights, and the maintenance of coverage trust fund obligations survive. Finally, it deletes Tennessee Code Annotated § 71-5-161 and takes effect July 1, 2026.

AT A GLANCE

This bill requires health insurance companies to reimburse physicians in Cook, DuPage, Lake, or Will counties for covered health care services at no less than 160% of the applicable Medicare rate.

FULL SUMMARY

The bill adds a new Section 368k to the Illinois Insurance Code establishing minimum reimbursement requirements for physicians in specified Illinois counties. It defines relevant terms (including “County” as Cook, DuPage, Lake, and Will; “covered health care service” as services for which a Medicare rate has been established at the time provided; “Medicare rate” as the applicable Medicare Physician Fee Schedule CPT rate in effect when services are rendered; and “physician” to include licensed physicians/osteopaths and advanced practice providers practicing under physician supervision).

Under the new Section 368k(b), a health insurance company must reimburse a physician for covered health care services provided in any of the covered counties at no less than 160% of the applicable Medicare rate for the same service. If Medicare establishes multiple payment rates for a service, subsection (c) requires calculating the reimbursement floor using the rate that most closely corresponds to the setting and type of service.

The bill makes lower-than-minimum reimbursement provisions void and unenforceable to the extent they conflict with the minimum reimbursement requirements. It also prohibits a physician from waiving the protections of the Section as a condition of participation in a health benefit plan or for any other reason. The Department of Insurance is directed to enforce the Section and may adopt rules to implement it.

Violations by a health insurance company subject the company to civil penalties up to $15,000 per individual violation, payment of restitution to the affected physician, and any additional remedies authorized by the Department.

AT A GLANCE

This bill prohibits health plan issuers from wrongfully denying, reducing, or terminating requested covered health care services or payments, and subjects violations to enforcement and enhanced penalties.

FULL SUMMARY

The bill establishes new requirements for health plan issuers regarding health care claim decisions, creates a “medical claims consumer assistance program” under the Superintendent of Insurance, and expands health insurance claim review and reporting duties. It prohibits health plan issuers from “wrongfully” denying, reducing, or terminating requested covered health care services or payments, and subjects violations to enforcement procedures and enhanced penalties.

For issuer misconduct, the bill creates a new section (Sec. 3901.216) defining the prohibition on wrongful denials/reductions/terminations, and sets enforcement via the existing unfair/deceptive insurance enforcement framework (Sec. 3901.22), with additional remedies. If the superintendent finds a violation, the superintendent may request the attorney general to sue in the name of the state, and the court may order (among other remedies) double damages to the covered person plus reasonable expert/attorney expenses, damages determined by the court, and a civil penalty up to $25,000 per violation; it may impose additional penalties for repeated violations and requires consideration of specified penalty factors. It also directs the superintendent to increase penalty amounts annually beginning one year after the effective date based on health insurance premium rate changes or inflation (using CPI), and sets out a detailed list of factors the superintendent or court must consider when determining penalties.

The bill creates the medical claims consumer assistance program (Sec. 3901.97), which the superintendent must establish to assist consumers with adverse benefit determinations and insurance coverage concerns. The program must provide information on internal appeals and external review processes, assist with filing complaints and appeals, help settle disputed claims, collect and quantify consumer problems and inquiries, educate consumers on rights/responsibilities, assist with enrollment information/referrals, assist consumers obtaining premium tax credits, and provide public outreach (including electronic resources and a toll-free number). The bill requires each health plan issuer to place a prominent plain-language notice about the program on the front page of health plan communications (including explanations of benefits and adverse benefit determination notices). It also allows the superintendent to incorporate existing department programs into the assistance program and to contract with a nonprofit independent entity, while barring health plan issuers and their subsidiaries/affiliates from serving as the administering entity.

The bill also revises independent review organization (IRO) review requirements (Sec. 3922.07) by adding additional materials and evidence that the IRO must consider where available and appropriate, including the covered person’s medical records, treating professional recommendations, consulting reports/documents from parties, plan terms, practice guidelines, clinical review criteria used by the issuer, the clinical reviewer’s opinion, and evidence of intent by the issuer to improperly deny/reduce/terminate. Separately, it requires health plan issuer data submissions and reporting by the superintendent (Sec. 3922.171), including the number/percentage/type of adverse benefit determinations (overall and found wrongful under the new wrongful standard) and the number/types of consumer-reported issues to the assistance program, with the superintendent required to submit the annual report to multiple state leaders and post it publicly in machine-readable format. Finally, it repeals existing sections 3901.22 and 3922.07 of the Revised Code and names the act the “Fair Health Claims Act.”

The document outlines significant amendments to New York's insurance and public health laws, focusing on utilization review determinations for health care services, particularly in mental health and substance use disorders. One of the key changes is the prohibition of health plans from reversing or altering medical necessity determinations made by utilization review agents or external appeal agents, unless fraud is involved. This measure aims to protect patients from retrospective audits that could adversely affect their care.

Additionally, the amendments clarify the definition of "medically necessary" services, ensuring that covered health care services are appropriate, evidence-based, and not primarily for the economic benefit of insurers. Emergency services, including those related to mental health and substance use disorders, are exempt from prior authorization and cannot be denied reimbursement on retrospective review if deemed medically necessary.

Utilization review agents are mandated to utilize peer-reviewed clinical criteria that align with medical and scientific evidence when assessing coverage for substance use disorder treatment and mental health conditions. These changes are expected to impact the health insurance industry, mental health service providers, and substance use disorder treatment facilities, necessitating adjustments to comply with the new regulations.

While specific monetary impacts are not detailed, the amendments could lead to increased costs for health plans due to the requirement to cover emergency services without prior authorization and the potential rise in claims for mental health and substance use disorder treatments.

AT A GLANCE

This bill requires Rhode Island’s Executive Office of Health and Human Services to calculate “enrollment-driven savings” for fiscal year 2028 Medicaid enrollment decreases and reallocate them to additively increase specified provider reimbursement rates.

FULL SUMMARY

The bill establishes a new Rhode Island statutory framework governing how Medicaid savings attributed to enrollment decreases must be calculated and reallocated within the Medicaid program for provider reimbursement increases.

It adds Chapter 169 to Title 42 of the General Laws, defining “enrollment-driven savings” as reductions in Medicaid expenditures in the fiscal year ending June 30, 2028, attributable to enrollment decreases, using estimates adopted at the May meeting of the Rhode Island caseload estimating conference. It requires that all such savings be retained within Medicaid and not used for deficit reduction or other purposes. The bill directs that the savings be reallocated exclusively to increase Medicaid provider reimbursement rates for (i) hospital inpatient services, (ii) hospital outpatient services, (iii) physician services, and (iv) federally qualified health center services. It also specifies that these funds must be additive to existing Medicaid reimbursement levels and must not supplant, replace, or offset existing appropriations, rate structures, or payment methodologies in effect as of June 30, 2026.

The executive office of health and human services must implement the reimbursement increases by adjusting Medicaid fee-for-service rates as needed; for managed care, amend contracts and/or implement state directed payments so the rate increases flow to providers with a minimum provider pass-through of at least 90% of each rate increase, implemented within 180 days of each rate adjustment; and submit any required state plan amendments, waivers, or federal approvals to the Centers for Medicare & Medicaid Services. The bill further requires an annual report to the General Assembly due no later than October 31 each year, including: the calculation methodology and actuarial assumptions for the enrollment-driven savings; itemized provider rate adjustments; total federal financial participation generated by the rate investments; the status of any required CMS approvals (including pending or denied); and managed care organization compliance with the 90% pass-through requirement.

The act takes effect July 1, 2026.

AT A GLANCE

This bill prohibits health insurers and pharmacy benefit managers from mandating white-bagging or brown-bagging for clinician-administered drugs unless specified provider or patient written agreements and consents are obtained.

FULL SUMMARY

The bill creates a new managed care law subdivision in RSA 420-J establishing definitions and safety/care requirements for “clinician-administered drugs” (outpatient prescription drugs, other than vaccines, that cannot reasonably be self-administered and are typically administered by authorized professionals in a clinical setting such as a physician’s office or infusion center).

It prohibits health insurers and pharmacy benefit managers (PBMs) from mandating “white bagging” (dispensing by a pharmacy selected by the insurer/PBM for delivery to the provider for administration) unless (1) there is a written agreement between the provider and dispensing pharmacy covering delivery, handling/storage, and liability responsibilities, and (2) the provider has provided prior written consent to use the arrangement.

It also prohibits health insurers and PBMs from mandating “brown bagging” (pharmacy dispensing to the patient for transport to the provider for administration) unless (1) there is a written attestation from both patient and provider that transporting the medication will not compromise care, and (2) both patient and provider have provided prior written consent.

Under the foregoing white-bagging and brown-bagging rules, the bill bars insurers/PBMs from interfering with an enrollee’s right to obtain clinician-administered drugs from the provider or pharmacy of choice, from limiting/excluding coverage solely because the drug is obtained from a non-selected pharmacy if it would otherwise be covered, from requiring extra patient cost-sharing (e.g., additional fees, higher copays/coinsurance, or other price increases) when the drug is not dispensed through an insurer/PBM-selected pharmacy, and from conditioning, denying, restricting, refusing to authorize, or reducing payment to participating providers for covered clinician-administered drugs and related services when medical necessity criteria are met, based on where the provider sources the drug (including if from a pharmacy not participating in the network or managed/owned by the PBM). The act takes effect January 1, 2027.

AT A GLANCE

This bill caps payments for applicable outpatient/ambulatory services at the lesser of 150% of the Medicare non-hospital rate or the negotiated rate and bars providers from billing above the cap.

FULL SUMMARY

The bill establishes New York’s “fair pricing” requirements for low-complexity, routine medical care delivered in outpatient/ambulatory settings (“applicable services”) by setting site-neutral payment limits and related billing rules. It defines key terms (including “site-neutral payment policy,” “applicable services,” “health care provider,” and “health benefit plan”) and designates certain provider types/facility categories excluded from coverage, including federally qualified health centers, certain Title X diagnostic and treatment centers, enhanced safety net hospitals, distressed safety net hospitals, and PPS-exempt cancer hospitals.

For applicable services, the bill bars a health care provider from charging, billing, or accepting payment for covered outpatient/ambulatory services above the lesser of (i) 150% of the Medicare non-hospital rate or (ii) the negotiated rate agreed with the health benefit plan; it applies even when there is no contract (including self-pay). It also prohibits using an institutional claim form when a professional claim form is appropriate for the same service, and forbids providers from billing both claim types for the same service. Providers contracting to participate with a health benefit plan must offer to accept as payment in full rates that do not exceed 150% of the Medicare non-hospital rate. It further limits beneficiary/self-pay liability so patients cannot be held responsible for amounts exceeding the capped rates (including copayments, deductibles, and/or coinsurance tied to prohibited billing).

The bill requires the Department of Health, starting one year after the section’s effective date, to publish an annual public report (with specified analytical and comparison elements) on multi-year spending trends and cost drivers for ambulatory services, including utilization/spend impacts relative to Medicare non-hospital rates, patient cost-sharing, volumes, total spending, identified hospitals charging in violation, state actions taken, and recommendations for further site-neutral pricing. It also requires annual posting of an official list of facilities exempt from the section (as described in the providers/exclusions framework). Violations by providers trigger administrative penalties, with the penalty set as the greater of $100,000 per contract occurrence or $1,000 per claim improperly billed. The bill makes provider violations (and certain related referenced insurance-law provisions) unlawful deceptive acts or practices under New York’s General Business Law, giving persons or entities who suffer a loss a private right of action for available remedies.

To align payor conduct, the bill adds multiple insurance-law restrictions and penalties: insurers, health benefit arrangements, employee welfare funds, and municipal cooperative health benefit plans that cover “applicable services” may not reimburse or contract for reimbursement above the provider rate caps, or reimburse services billed in violation of the bill’s claim-form rules. It authorizes the superintendent/department (depending on the insurance-law section) to impose civil penalties up to $50,000 per day for each day a contract is in violation. The bill also directs joint regulations by the commissioner of health and the superintendent of financial services to implement its requirements, and sets an applicability/effective-date structure: it takes effect on January 1 next succeeding enactment/when it becomes law, and applies to policies and contracts issued, amended, or renewed on or after that date, with implementation-related rulemaking authorized to be completed by the effective date.

The General Assembly of North Carolina is implementing significant changes to enhance transparency and affordability in healthcare. Rising healthcare costs have become a burden for individuals, families, employers, and taxpayers, prompting the need for price transparency. The new regulations require healthcare providers and insurers to disclose prices for services in advance, enabling consumers to make informed choices and fostering competition among providers.

Hospitals and ambulatory surgical facilities will be mandated to report financial information related to inpatient admissions and surgical procedures, including charges for Diagnosis-Related Groups (DRGs) and average negotiated settlements. These reporting requirements aim to improve transparency in healthcare costs and ensure compliance with federal regulations. Additionally, healthcare providers must provide written disclosures regarding potential separate billing for nonparticipating providers, enhancing consumer protection.

New provisions will also require healthcare facilities to provide patients with itemized lists of charges before referring unpaid bills to collections. Patients requesting good-faith estimates for shoppable services will not face final bills exceeding five percent of the provided estimate, and healthcare providers are restricted from charging facility fees for certain outpatient services. These changes are designed to improve patient experience and financial clarity.

The regulations also address the appeals process for health insurance claims, ensuring that insurers provide clear information about appeal coordinators and the qualifications of reviewers. Changes to prior authorization and utilization review procedures will require insurers to enhance their communication with covered persons and ensure that prior authorizations remain valid for specified periods.

Overall, these initiatives aim to create a more transparent and consumer-friendly healthcare environment in North Carolina, ultimately improving access and reducing unexpected costs for patients.

AT A GLANCE

This bill requires health insurers and Medicaid to reimburse insureds for the same covered services when performed by licensed physician assistants or certified nurse practitioners within their lawful scope.

FULL SUMMARY

The bill establishes “equal pay” reimbursement rules for health insurance when covered services are within the lawful scope of practice of licensed physician assistants or certified nurse practitioners. It requires that, whenever a health insurance policy reimburses services performed by licensed physicians, the insured is entitled to reimbursement for the same services when performed by a licensed physician assistant or certified nurse practitioner (including prescribing/dispensing and certain primary care or mental health services) as long as the services are within the practitioners’ lawful scope.

For physician assistants or nurse practitioners who are in an “independent practice,” the bill requires reimbursement to be paid “in the same amount” as reimbursement paid under the policy to a licensed physician performing the service in the area served. It defines “independent practice” as a setting where the physician assistant or nurse practitioner bills insurers for services using the practitioner’s own name and national provider identifier, and it directs that the equal reimbursement requirement applies to services provided by physician assistants and certified nurse practitioners who qualify under the stated scope conditions.

The bill contains two principal limitations and protections: (1) it does not apply to federally qualified group practice health maintenance organizations (and similar insurers) that do not compensate such practitioners on a fee-for-service basis; and (2) it prohibits an insurer from reducing reimbursement paid to licensed physicians in order to comply with the new equal-pay requirement.

These requirements are added in three insurance contexts—accident and sickness insurance policies and nonprofit medical service/corporations (new sections added to Chapters 27-18, 27-19, and 27-20)—and a Medicaid-related provision is added to the Medical Assistance chapter. For Medicaid, the executive office of health and human services (EOHHS) must provide for reimbursement starting January 1, 2027, and the bill requires submission of a Medicaid state plan amendment by October 1, 2026 after applying to the federal Department of Health and Human Services as needed. The act takes effect January 1, 2027.

AT A GLANCE

This bill requires EOHHS to expand patient-centered medical home coverage to all Medicaid-accepting independent primary care practices and nurse practitioners and to require MCOs to pay enhanced PMPM supplements.

FULL SUMMARY

The bill establishes a new Rhode Island statutory chapter (Title 27, Chapter 18.10) called the “Medicaid and Commercial Primary Care Rate Enhancement and Sustainability Act,” directing state agencies to expand patient-centered medical home (PCMH) coverage for independent primary care providers and to increase Medicaid and commercial/Medicare Advantage primary care payments using state-directed payments under 42 C.F.R. § 438.6(c).

EOHHS is required to expand the PCMH program to all Medicaid-accepting independent primary care practices and nurse practitioners, and to require managed care organizations (MCOs) to pay an enhanced per-member-per-month (PMPM) supplement of $10 to $20 for each attributed Medicaid patient to eligible independent providers who enroll in PCMH or meet equivalent criteria.

EOHHS must accelerate the FY2026 primary care rate increase to 100% of Medicare and add a temporary 25% bonus for independent (non-hospital-employed) practices. Through state-directed payments, EOHHS must also require MCOs to pay an automatic access payment supplement of $8 to $15 PMPM for every attributed Medicaid patient in qualifying independent practices.

The Office of the Health Insurance Commissioner must require commercial insurers and Medicare Advantage plans to align primary care reimbursement rates with those in Massachusetts and Connecticut via phased implementation: 15% by January 1, 2027 and full alignment by July 1, 2027. Eligibility is limited to independent primary care physicians and nurse practitioners accepting Medicaid and meeting minimal quality/reporting requirements set by EOHHS. On or after January 1, 2027, EOHHS must submit state-directed payment preprints to CMS, update MCO contracts, build on the existing multi-payer PCMH program (OHIC, with Care Transformation Collaborative of Rhode Island), and issue annual reports on access, retention, and cost savings; OHIC must amend regulations and insurer contracts to enforce commercial parity. The commissioner and EOHHS must enforce the chapter under existing authority, and non-compliant contract provisions are void. The act takes effect January 1, 2027.

AT A GLANCE

This bill requires the funded state departments and agencies to publicly post required fiscal integrity and program reports on Michigan.gov in a single archive and email them to designated recipients.

FULL SUMMARY

The bill establishes line-item appropriations for multiple state departments and agencies for the fiscal year ending September 30, 2027, including funding for the Department of Agriculture and Rural Development, the Department of Corrections, and the Department of Education, and it authorizes specified one-time appropriations within those departmental budgets. It also sets a defined total of state spending payable to local units of government from state sources and includes an itemized list of agriculture-related grant programs through which that local spending occurs.

Across the agriculture and corrections portions, and for the education portion as described, the bill imposes standardized fiscal integrity and transparency requirements on funded departments and agencies, including public posting of required reports on Michigan.gov in a single archivable location with email delivery to designated “standard report recipients.” It requires procurement-related compliance that permits preferences for American goods and Michigan businesses (including Michigan veteran-owned businesses where allowed), protects employees from disciplinary retaliation for communicating with legislators or staff unless otherwise prohibited by law, and mandates out-of-state travel reporting and quarterly reporting of staffing using authorized-versus-employed FTE measures. It further applies controls tied to contingency authority and carryforward/work-project treatment for specified appropriations, and it requires a range of program- and operations-level reporting, including items such as staffing, travel allocations, health-care utilization and treatment reporting within corrections, and other operational metrics identified for particular programs.

For the Department of Corrections, the bill appropriates funding through multiple functional and facility-related line items and directs operational reporting on offender population metrics and projections. It also creates or governs a county jail reimbursement framework with defined eligibility categories, per-diem reimbursement amounts, documentation and reporting requirements, and appropriation-linked caps, and it includes additional specified requirements related to health-care reporting, prisoner phone systems, overtime and critical-incident related reporting, vendor contract reporting for large contracts, wellness programming, and facility ratio and related operational compliance.

For the Department of Education, the bill provides line-item appropriations across administrative, technology, special education, library, and district support functions, including specified one-time appropriations, and it applies the same cross-cutting transparency, procurement-permitted preferences, communications non-retaliation, out-of-state travel reporting, contingency/carryforward structures, workforce/office occupancy monitoring concepts, and strategic plan and legislatively directed spending disclosure requirements. It also adds program-specific operational requirements regarding distribution of special education parent/guardian information, handling of Michigan Schools for the Deaf and Blind-related services and information for intermediate school districts, educator certification and assessment tied to evidence-based literacy instruction, Medicaid-related technical assistance tied to mental health use of Medicaid dollars, and reporting tied to any included teacher certification test pilots.

AT A GLANCE

This bill prohibits health care providers from charging facility fees for covered outpatient and emergency-center services except in specified hospital-campus, hospital-emergency-department, or freestanding-emergency-center circumstances.

FULL SUMMARY

HB4701 establishes the “Limitations on Facility Fees Act,” creating new limits on when health care providers may charge, bill, or collect “facility fees” for certain outpatient services and emergency-center settings.

Under the Act, a health care provider generally may not charge a facility fee except in three site-specific circumstances: (1) services provided on a hospital’s campus; (2) services provided at a facility that includes a licensed hospital emergency department; or (3) emergency services provided at a freestanding emergency center. In addition, the Act imposes service-specific limits: notwithstanding the site rules, no facility fee may be charged for outpatient evaluation and management services, or for other outpatient diagnostic or imaging services that the Department of Public Health identifies through its annual process.

The Department must annually identify which outpatient diagnostic or imaging services may reliably be provided safely and effectively in settings other than hospitals; the identified services are those for which facility-fee limitations do not apply under the Act’s service-specific restrictions. The Act also requires annual reporting by each hospital, health system, and freestanding emergency center to the Department about facility fees charged or billed during the preceding calendar year, including facility locations, patient-visit counts, Medicare/Medicaid/private insurance amounts and ranges, hospital-based facility and provider/system-wide revenue totals from facility fees, and detailed “top 10” procedures/services (by both fee gross revenue and patient volume) using CPT category I code groupings, plus other information the Department may require. Providers must also make relevant books, documents, records, or data available to the Department (or its designee) for audit purposes until four years after furnishing services for which a facility fee was charged, billed, or collected.

The Department may adopt rules to implement the Act, including reporting formats/content and penalties for noncompliance. Enforcement treats violations as unlawful practices under the Consumer Fraud and Deceptive Business Practices Act, and authorizes administrative penalties up to $1,000 per occurrence. The bill also: (1) amends the Fair Patient Billing Act’s Section 12 to align with the new facility-fee limits while retaining the requirement that hospitals develop patient-notification policies when charging facility fees separate and distinct from professional fees; and (2) adds a new provision to the Consumer Fraud and Deceptive Business Practices Act stating that any person who violates the Limitations on Facility Fees Act commits an unlawful practice.

AT A GLANCE

This bill requires health care insurers to include specified in-state facilities and clinicians and meet region-based in-network percentage minimums, subject to the Alaska Director of Insurance’s limited-network exceptions.

FULL SUMMARY

The bill establishes minimum standards for health insurance provider networks and directs the Alaska Director of Insurance to account for certain “limited network” requirements when setting or approving covered-person benefits or related contractual requirements.

For provider networks, a health care insurer must include (1) every in-state hospital, skilled nursing facility, and licensed mental health or substance abuse facility, and (2) in-state physicians, physician assistants, or advanced practice registered nurses employed or contracted by those facilities, plus analogous requirements for facilities and clinicians operated/employed/contracted by Alaska tribal health organizations. The insurer must also include a sufficient number of in-region clinicians in each contracting region (and only clinicians meeting specified licensing/credentialing and principal-practice-location conditions may be counted under defined circumstances), with all included clinicians shown as in-network in the insurer directory.

The bill divides Alaska into six contracting regions and imposes percentage minimums for inclusion of actively practicing physicians/PA/APRNs by specialty and provider groups, using Centers for Medicare and Medicaid Services Medicare Advantage “network adequacy” specialty/provider-group categories. The required percentages vary by region: 70% for Anchorage; 75% for the Matanuska-Susitna Borough and the Fairbanks North Star Borough/Southeast Fairbanks Census Area; and 80% for the Kenai Peninsula Borough, the Juneau/Ketchikan Gateway/Sitka region, and the remainder of the state. The Director may grant exceptions from the minimum network standards for limited periods (not exceeding 36 months), subject to procedures/regulatory standards, and insurers must annually attest compliance and, if they do not meet a specific standard, submit a corrective-action plan; the Director may also adopt additional higher standards by region.

Separately, the bill creates standards for settlement of health insurance claims in the absence of a contract setting allowable charges. The Director must set regulations requiring insurers to use a statistically credible methodology to establish “allowable charges” for in-state services/supplies, based on the most current 12-month provider-charged data, uniformly applied statewide, and at least 345% of the applicable federal CMS physician fee schedule for the state in effect at delivery. The Director must periodically audit/validate insurer methodology. Insurers must review/update allowable charges no more often than every three years and at least every five years unless otherwise directed. The bill also requires uniform and equal reimbursement-rate application for a given service/supply type and authorizes definitions for “allowable charge,” “health care insurer,” and “health care provider.” A transition rule requires allowable charges for calendar year 2027 to use the most current data based on 12-month periods beginning in 2024 or earlier, and takes effect January 1, 2027; it also repeals AS 21.07.020(3).

AT A GLANCE

This bill requires health insurers’ provider contracts to pay clean claims within 40 days of receipt and comply with specific “ethics and fairness” processing and notice standards.

FULL SUMMARY

The bill amends Virginia’s health insurance claim-processing and provider-contract requirements by revising §§ 38.2-3407.15 and 38.2-3407.15:8. It establishes detailed “ethics and fairness” standards for carrier handling of provider claims (including payment timing, clean-claim rules, notice of defects, dispute and downcoding requirements, limits on retroactive denials/recoupment, required contract contents, and electronic communication requirements beginning in 2025–2026) and creates/updates requirements governing required prior-authorization contract provisions for health care services, effective January 1, 2027.

Section 38.2-3407.15 (ethics and fairness in carrier business practices) requires provider contracts to include minimum fair business standards: pay claims within 40 days of receipt with specified exceptions; maintain claim-receipt records and allow provider inspection; require notice within 30 days of claim defects preventing clean-claim status; mandate payment after receipt of required additional information; ensure interest is paid without demand; require offering alternative payment methods without transaction fees; establish medically-necessary/covered-benefit verification mechanisms during business hours; require carriers to implement and disclose bundling and downcoding policies and to downcode only using correct coding standards that consider all relevant patient data, with provider notice, explanation-of-payment codes, and a dispute process (including natural-person review of downcoding dispute decisions and minimum dispute timelines); require providers be given applicable policies within 10 business days (or a compliant copyright workaround explanation); and require payment of previously authorized/medically necessary covered services unless specific enumerated grounds apply.

The bill further tightens restrictions on retroactive denial/recoupment by prohibiting such actions unless the carrier specifies the affected claim(s), provides a written explanation, and satisfies fraud/incorrect-payment/12-month timing limits (with an exception allowing written agreement to offset after 12 months); requires 30-days advance notice for retroactive denials/recovery; requires provider contracts to include required fee/reimbursement information; restricts effectiveness of contract amendments/new policies unless the provider receives the material at least 60 days before effective date and has at least 30 days to notify intent to terminate; requires establishment of the claims payment dispute mechanism and treats overturn of denials as clean claims; prohibits provider discrimination based on enrollee status as a litigant; and requires electronic means for providers to determine enrollee coverage beginning July 1, 2025. It also requires that a provider generally make a reasonable effort to confer with the carrier before filing a Commission complaint for failure to pay claims (subject to timing/responsiveness conditions), provides Commission and Board mechanisms for patterns of potential subdivision B 13 violations, and defines enforcement/relief including actual damages (and up to treble where gross negligence and willful conduct are found), attorney fees/costs, and a no-termination/penalty protection for providers invoking rights. Electronic-only delivery of provider contracts/amendments/notices is mandated beginning July 1, 2025 for carriers (and January 1, 2026 for providers), with agreed electronic method/location in the contract.

Section 38.2-3407.15:8 (effective January 1, 2027) requires provider contracts to include prior-authorization process rules for carriers, distinguishing expedited vs. standard requests. Contracts must require electronic/telephonic decisions within 72 hours (including weekends) for expedited requests and within seven calendar days for standard requests, including supplementation timelines; prohibit revocation/limitation/modification of approved authorizations except for enumerated circumstances (provider-requested changes, fraud/misrepresentation evidence, or certain federal/manufacturer market removals/limits impacting the authorization, or patient safety communications), and clarify that carriers need not authorize if the enrollee is no longer enrolled. Denial communications must also occur within the same expedited/standard timeframes; carriers must establish and maintain a prior-authorization application programming interface (API) consistent with CMS requirements (42 C.F.R. § 422.122(b)) and must be implemented by January 1, 2027 (or other subsequently issued CMS effective date), while providers must ensure their electronic health records/systems can access the API within one year after the API implementation requirement date, with a possible waiver for undue hardship determined by the appropriate HHS Secretariat-designated regulatory authority. The section also requires carriers to publish and update a central list of services/codes requiring prior authorization (with provider notice at least 30 days before changes) and prohibits denial of claims for failure to obtain prior authorization when the requirements for that date of service were not posted accordingly; it permits removal of prior authorization requirements without the 30-day notice in pandemics/natural disasters/emergencies; and requires annual posting (by March 31) of prior authorization data at the health plan level for required metrics.

Finally, the bill amends reenactment language from 2023 by directing the State Corporation Commission’s Bureau of Insurance, in coordination with the Secretary of Health and Human Resources, to establish a work group to monitor and evaluate federal developments and readiness for electronic prior authorization, assess the state prior-authorization process (including potential shift toward less retrospective to more prospective processes for prescription drugs), evaluate whether metric reporting scope should expand to prescription drugs, include specified stakeholder groups, and submit periodic reports: an initial final report findings/recommendations due by November 1, 2025 (with final assessment and a recommended implementation date for electronic prior authorization for medical items/services) and an eventual final report due by November 1, 2028.

AT A GLANCE

This bill requires participating hospitals to provide inpatient and outpatient care to eligible uninsured and low-income patients, including paying no cost up to 200% FPL and subsidizing care above that level.

FULL SUMMARY

The bill establishes a voluntary hospital financial assistance program effective October 1, 2026. Participating hospitals must provide inpatient and outpatient care for eligible patients by: (1) providing care at no cost to uninsured patients with income up to 200% of the federal poverty level (FPL); (2) providing subsidized care for uninsured patients with income above 200% but not exceeding 300% FPL; (3) providing subsidized care for patients with income up to 400% FPL who are enrolled in SNAP or WIC; and (4) for patients with household income under 200% FPL who are deemed ineligible for hospital financial assistance, billing on a payment schedule capped at no more than 2% of annual household income. After 36 cumulative months of payments under this capped schedule, participating hospitals must consider the patient’s hospital bill paid in full and permanently cease any collection activity on any remaining unpaid balance.

Participation triggers several eligibility/documentation limits. Participating hospitals may not count patient assets to determine eligibility and may not require proof that applications for specified public or other coverage (state medical assistance/Medicaid, Emergency Medicaid, Medicare, or Connecticut Health Insurance Exchange coverage) were denied. Hospitals must use software meeting industry standards for electronic income verification and may accept specified documents to verify income (recent tax return; W-2 and 1099s; two most recent pay stubs; or employer written verification for cash-paid patients). Hospitals must exempt patients experiencing homelessness or imminently at risk from providing documentation, while allowing self-attested information for screening and application. The bill also requires participating hospitals to make information about the program available in the top non-English languages spoken by at least 5% of the population in the hospital’s geographic service area, included in discharge paperwork and on the hospital website, with Office of the Health Care Advocate contact information and ADA-compliant effective communications.

The bill authorizes reimbursement of participating hospitals through Medicaid’s disproportionate share hospital payments (DSH). The Commissioner of Social Services must amend the Medicaid state plan to use DSH payments to compensate hospitals that participate in the hospital financial assistance program, and must establish criteria for participating hospitals to document financial assistance and receive timely payment. A hospital aggrieved by a final commissioner decision on the validity of the hospital’s bills for hospital financial assistance may pursue a rehearing and then appeal using the referenced existing process.

In addition to creating the hospital program and DSH reimbursement framework, the bill changes the rehearing/appeal procedure in the DSS payment/rate context by repealing and substituting a revised subsection 17b-238(b) (effective October 1, 2026) and further making a technical update to that subsection effective January 1, 2027. The bill sets an effective date of October 1, 2026 for the new sections (with the hospital rehearing provision taking effect January 1, 2027).

AT A GLANCE

This bill requires health carriers to deliver provider contracts, notices, and amendments exclusively in specified electronic format by July 1, 2025, and requires providers to submit them the same way by January 1, 2026.

FULL SUMMARY

The bill revises Virginia’s health insurance “ethics and fairness in carrier business practices” statute (Va. Code § 38.2-3407.15), with particular emphasis on claim-payment timelines and electronic communications for providers.

It updates carrier and provider obligations in the provider-contract minimum fair business standards, including: (1) adding explicit requirements for carriers to deliver required notifications and related provider responses electronically starting January 1, 2026 (for the notice-of-defect/impropriety process tied to making a claim a “clean claim”); (2) likewise requiring electronic delivery for written communications and explanations for retroactive denials/recoveries/refunds related to previously paid claims, beginning no later than January 1, 2026; (3) adding an express requirement that carriers make available through electronic means, beginning July 1, 2025, a way for providers to determine whether an enrollee is covered by a health plan subject to the State Corporation Commission’s jurisdiction; and (4) tightening electronic-format contracting and notice flows by requiring that (a) beginning no later than July 1, 2025, carriers deliver provider contracts, related amendments, and notices exclusively in an electronic format other than electronic facsimile, and (b) beginning no later than January 1, 2026, providers submit provider contracts, amendments, and notices to carriers exclusively in such electronic format.

The bill also clarifies/strengthens enforcement and provider remedies tied to the statute’s existing framework: providers may sue to recover actual damages for carrier violations/breaches; if gross negligence and willful conduct are found, damages may be increased up to three times actual damages; and violating claims are treated as separate violations for damages/fee purposes (attorney fees and court costs may be awarded). It preserves prohibitions on carriers terminating/penalizing providers for invoking rights under the section, maintains the Commission’s limited role (no adjudication of individual controversies), and directs that the Commission may promulgate rules to implement the section.

The bill sets an effective date of January 1, 2027.

AT A GLANCE

This bill prohibits Ohio from renewing or entering financial risk-bearing Medicaid managed care contracts beginning the first day of the relevant fiscal biennium after ASO contracts.

FULL SUMMARY

The bill establishes a major restructuring of Ohio’s Medicaid program by eliminating the “care management system” (a system of financial risk-bearing Medicaid managed care) and replacing it with a state-administered administrative services organization (ASO) / managed fee-for-service framework. It creates and revises multiple Medicaid provisions to: (1) convene a transition workgroup; (2) require procurement and federal approvals; (3) prohibit renewal/new contracts with financial risk-bearing Medicaid managed care organizations beginning the first day of the relevant fiscal biennium after ASO contracts; (4) direct the transition of enrolled Medicaid recipients from managed care plans to fee-for-service or managed fee-for-service; (5) require termination of those managed-care contracts after transition, with 30 days’ notice; and (6) mandate an annual report to the General Assembly and Governor and reinvestment of 100% of savings into the Medicaid program.

Operative Medicaid process changes include: updating Medicaid budget forecasting and state budget appropriation item requirements to explicitly separate “services provided under the care management system” and other service categories (with an “effective” state-budget timing requirement tied to the Sept. 30, 2025-introduced budget); modifying prior-authorization-related requirements for Medicaid service coverage (including electronic workflows, timelines, streamlined appeals, and limits on certain types of retroactive denials except for fraud/materially incorrect information); and modifying Medicaid third-party recovery administration to include cooperation and procedural protections (including hearings/administrative appeal mechanics, presumptions about allocation, escrow mechanisms, and new cooperation obligations tied to disclosure of third-party liability).

The bill also enacts new Medicaid program components and related definitions, including a “healthy Ohio program” (a medicaid waiver component for certain adults) with buckeye accounts and participation rules, and it creates an evaluation/reporting structure for program effectiveness. Separately, it creates an ASO transition framework at the statutory level, including definitions for ASOs, care coordination, and managed fee-for-service, and requires data collection/reporting from Medicaid managed care organizations during evaluation and transition. It also modifies or relocates provisions within Medicaid law by adopting a new section number (5162.73 (5162.74) is amended for renumbering) and enacts a new section number (5162.73), with related dental-program and evaluation requirements shown in the text.

In addition to Medicaid changes, the bill makes broad statutory edits outside Medicaid. It repeals a list of existing Revised Code sections that are directly tied to the care management/Medicaid managed care structure and related franchise fee components, and it repeals multiple non-Medicaid provisions across insurance/pharmacy/telecommunications tax definitions and other areas (as reflected by the repealer sections listing many Revised Code sections). It also adds extensive, detailed content affecting the state’s prescription drug monitoring database confidentiality/use rules, prior authorization/payment processes, and other regulatory definitions that are consistent with the bill’s broader “Medicaid Savings Act” objective. The act is named the “Medicaid Savings Act.”

AT A GLANCE

This bill requires Ohio Medicaid to terminate the risk-bearing Medicaid managed care care management system and transition all recipients to an ASO-administered fee-for-service or managed fee-for-service model.

FULL SUMMARY

The bill establishes the “Medicaid Savings Act” and directs Ohio Medicaid to eliminate the care management system. It creates/renumbers section 5162.73 (5162.74) and enacts new section 5162.73, and also includes the repeal of numerous Medicaid-related statutory sections, including the “care management system” provisions and definitions under Revised Code chapters 5167 and related sections.

Program budgeting and forecasting are modified to reduce reliance on care management-system reporting while still requiring Medicaid budget forecasting components to reflect enrollment and spending categories. Specifically, the caseload/expenditure forecast report to the Governor and General Assembly is updated to reflect the care management system’s enrollment and spending components (including member months and per member per month rates), and the bill changes the structure of Medicaid services general revenue fund appropriation items starting with the state budget introduced after the section’s effective date (including a dedicated item for services under the care management system and other specified service categories such as nursing facility services, hospital services, behavioral health services, waiver-administered services, prescriptions, physician services, and Ohio home care waiver services; it also adds OhioRISE waiver services and permits additional service items determined by the directors).

A major substantive operational change replaces risk-bearing Medicaid managed care with administrative services and fee-for-service (or a “managed fee-for-service” model) through an ASO-based transition. New/updated sections require: (1) convening a stakeholder workgroup to develop a transition plan for terminating the former care management system; (2) selecting one or more administrative services organizations through procurement and adopting implementing rules; (3) seeking necessary CMS federal approvals; (4) not renewing or entering new contracts with financial risk-bearing Medicaid managed care organizations beginning in the first fiscal biennium after ASO contracts are entered; (5) transitioning all Medicaid recipients from financial risk-bearing managed care plans to fee-for-service or managed fee-for-service; (6) terminating existing contracts and providing notice to managed care organizations; and (7) requiring that 100% of “cost savings” realized from terminating the care management system be reinvested into the Medicaid program. The bill also requires an annual report to the General Assembly and Governor, including savings metrics and clinical/resource utilization outcomes for recipients transitioning to the ASO system.

In parallel, the bill repeals large portions of current Medicaid care management law and related provider/administration provisions, including Revised Code sections governing the care management system and its components (notably in R.C. 5167 and specified related sections listed for repeal). It also amends several other statutory provisions not limited to Medicaid (e.g., medical records copying limits in R.C. 3701.741; parts of prescription drug monitoring/disclosure rules under R.C. 4729.80 and related sections; and updates to various insurance/credentialing and health care financing provisions), and it modifies Medicaid payment administration concepts such as electronic claims submission and drug maximum allowable cost and franchise fee framework that depends on member-months while the care management system is being terminated/transitioned.

The recent legislative changes significantly impact the regulation of pharmacy benefit managers (PBMs) in Wisconsin, focusing on enhancing transparency, fairness, and accessibility in pharmaceutical pricing and reimbursement practices. Key provisions require PBMs to pay pharmacies a professional dispensing fee that matches state medical assistance rates and prohibit them from imposing fees that would require remuneration from pharmacies. Additionally, PBMs must allow any licensed pharmacy to participate in their networks under the same terms and cannot charge different copayments based on network participation.

The legislation mandates that PBMs maintain and provide access to maximum allowable cost (MAC) lists, which must be updated promptly in response to price changes. Pharmacies are granted the right to appeal MAC determinations that fall below their acquisition costs, with PBMs required to resolve these appeals within a specified timeframe. Furthermore, PBMs are prohibited from discriminating against 340B covered entities and must ensure that all pharmacies in a preferred network are reimbursed at the same rates.

Auditing practices are also addressed, with requirements for uniformity in audits across similar pharmacies and restrictions on recouping reimbursements for errors that do not result in financial harm. PBMs must deliver final audit reports within a designated period and cannot retaliate against pharmacies for reporting violations or exercising their rights under the new regulations.

Health insurance policies are required to apply amounts paid for brand-name prescription drugs towards cost-sharing requirements, ensuring that patients' out-of-pocket expenses are minimized. Additionally, advanced written notice must be provided to enrollees regarding formulary changes, ensuring stability in medication options for those currently using affected drugs.

Overall, these changes aim to create a more equitable and transparent environment for pharmacies, pharmacists, and patients, significantly impacting the pharmacy and healthcare industries in Wisconsin.

The proposed legislation introduces comprehensive reforms to the regulation of pharmacy benefit managers (PBMs) in Wisconsin, focusing on enhancing transparency, fairness, and accountability in the pharmaceutical supply chain. Key provisions require PBMs to pay pharmacies a professional dispensing fee that matches state rates and prohibit them from imposing various fees on pharmacies. Additionally, PBMs must allow any licensed pharmacy to participate in their networks under the same terms and conditions, ensuring equitable access for all pharmacies.

The legislation mandates that PBMs provide detailed maximum allowable cost lists to pharmacies, update these lists promptly, and establish an appeal process for pharmacies contesting low reimbursement rates. Furthermore, PBMs are required to notify enrollees of formulary changes well in advance and cannot remove drugs from formularies except at coverage renewal times. This aims to provide stability for patients regarding their medication options.

PBMs are also tasked with acting in the best interests of health benefit plan sponsors, including annual disclosures of profits and payments to consultants. They must remit payments for claims within 30 days and cannot discriminate against 340B covered entities in reimbursement practices. The legislation prohibits PBMs from retaliating against pharmacies for reporting violations or exercising their rights, fostering a more supportive environment for pharmacies.

Auditing practices are also addressed, requiring uniform standards for audits and prohibiting recoupments for errors that do not cause financial harm. The legislation aims to standardize reimbursement rates among pharmacies and protect pharmacies from unfair practices, ultimately benefiting consumers by improving access to pharmaceutical products.

Overall, these changes are designed to create a more transparent and equitable pharmaceutical landscape in Wisconsin, impacting the operations of PBMs, pharmacies, and health insurance providers significantly.

AT A GLANCE

This bill requires Iowa health benefit plans to cover emergency services and participating-facility emergency care from out-of-network providers, while limiting out-of-network billing to covered cost sharing.

FULL SUMMARY

The bill creates a new Iowa statutory section, defining terms for “emergency services,” “out-of-network provider,” “participating facility/provider,” and “complicating factor,” and establishes new requirements for coverage and reimbursement of emergency care provided by out-of-network providers.

For policies, contracts, or plans providing third-party payment or prepayment of medical expenses, the bill requires coverage of services furnished by an out-of-network provider in two situations: (1) when the services are emergency services; or (2) when the services were provided at a participating facility and the covered person could not receive the services from a participating provider. It also limits patient billing by prohibiting an out-of-network provider from billing or collecting from the covered person any amount other than the covered person’s cost sharing under the health benefit plan.

The bill sets a claims and reimbursement process for out-of-network providers: the provider must submit a claim to the covered person’s health carrier within 60 calendar days after providing the services; the carrier must reimburse within 60 calendar days after receipt, and the reimbursement must be the greater of (a) the median amount that would have been paid to a participating provider in the same specialty (excluding cost sharing) or (b) 150% of the most recently published federal CMS fee schedule for the service (excluding cost sharing). For services involving a “complicating factor,” the out-of-network provider may seek additional reimbursement as part of the initial claim by submitting medical records/clinical documentation demonstrating the complicating factor; the carrier must either pay an additional amount equal to 25% of the initial reimbursement or issue a denial within 30 calendar days.

If the carrier denies the additional reimbursement, the provider may request binding arbitration with the commissioner, and the bill prescribes arbitration mechanics and timing: the commissioner notifies the parties within 30 days whether the request is accepted/denied; the carrier must submit reconfirmation or an alternative payment offer within 30 days after notice; the parties select an arbitrator from an approved list; and the arbitrator issues a written decision within 45 calendar days, considering specified documentation and payment offers. Arbitration costs must be split equally by the carrier and provider. The bill applies to enumerated types of specialized health-related insurance contracts/policies/plans delivered, issued, continued, or renewed in Iowa on or after January 1, 2027, and it excludes certain coverage types (e.g., accident-only, specified disease, short-term limited hospital/medical, disability income, workers’ compensation/similar supplements, and automobile medical payment insurance). The commissioner of insurance is authorized to adopt rules to administer the new section.

AT A GLANCE

This bill requires the Commonwealth Connector Authority to offer a public health benefits plan through the Connector for eligible individuals and small groups by January 1, 2027, and for eligible large groups by July 1, 2027.

FULL SUMMARY

The bill establishes a new Massachusetts public health insurance option administered through the Commonwealth Connector. It adds a new chapter 176S creating the “Public Health Insurance Option,” requiring the Commonwealth Connector Authority to offer a public health benefits plan exclusively through the Connector to eligible individuals and groups, alongside Connector “seal of approval” plans. The public option must meet the Connector’s seal-of-approval requirements, minimum creditable coverage standards, and applicable requirements from ch. 176Q; it is required for eligible individuals and eligible small groups by no later than January 1, 2027, and for eligible large groups by no later than July 1, 2027.

The bill sets administration and oversight requirements for the public option, including permitting the Connector’s executive director to contract with managed care organizations or other health benefits administrators. It requires collaboration among the executive director, the Secretary of Health and Human Services, and the Commissioner of Insurance so that (as of January 1, 2026) only Medicaid managed care organizations already under contract with the Commonwealth may administer aspects of the public option; it allows applications from non-Medicaid managed care organizations after January 1, 2027. It requires annual reporting in the Connector’s annual reports on activities, receipts, expenditures, and enrollments, with oversight by the Connector Board and the state auditor as specified in ch. 176Q. It directs the Connector to set premium rates sufficient to fully finance the costs of benefits and related administrative costs.

For provider reimbursement and participation, the bill requires the Connector Board to set payment rates for public-option services and providers based on Medicare parts A and B, with Board discretion to adjust those base Medicare rates to maintain fair reimbursement and a strong provider network. It provides an opt-out mechanism for health care providers participating in Medicare so that no provider faces a penalty for not participating, the Connector must provide information on how providers can opt back in, and there must be an annual provider enrollment period to decide participation.

The bill also creates a related financing and risk-adjustment structure by amending multiple provisions of Massachusetts law. It authorizes the Commissioner of Insurance (by inserting new ch. 26 §8K) to assess risk-adjustment payments among “risk-adjusted health plans” and to make payments when a plan’s actuarial risk exceeds the average actuarial risk across risk-adjusted plans; self-insured group health plans under ERISA are exempt. It requires the Commissioner to set criteria and methods, allows use of actuarial and utilization/diagnosis and cost data (in a confidentiality-limited way), and includes a technical amendment to remove two specified last sentences of a prior 2006 session law section. The bill creates a new “Public Health Insurance Option Trust Fund” in ch. 29, requiring that amounts credited to the fund be expended without further appropriation for operation of the public option, and requires an updated revenue report by the Comptroller not later than January 1 to multiple specified offices and committees. Finally, it amends ch. 176Q to add definitions and cross-references expanding Connector “seal of approval” and underwriting-related provisions to “eligible large groups,” and it requires that no later than July 1, 2026 the Connector Board extend its seal of approval to large group plans and offer such plans alongside the public health insurance option for large groups through the Connector.

AT A GLANCE

This bill requires Massachusetts insurers to pay licensed ambulance service providers directly and promptly for emergency ambulance services to covered insureds when the provider lacks a contract with the insurer.

FULL SUMMARY

The bill creates a new Section 3C in Massachusetts General Laws chapter 176D to govern how insurers must pay ambulance service providers for emergency ambulance services when the provider is not under contract with the insurer covering the insured.

In defining the rule, the bill specifies key terms for “ambulance service provider” (licensed by the Department of Public Health), “emergency ambulance services” (emergency services rendered under an ambulance service license where immediate medical attention is needed), “insurance policy”/“insurance contract” (coverage for ambulance transportation services issued within Massachusetts), “insured,” and “insurer” (a list of Massachusetts-regulated insurance and health plan entities).

Operationally, if an ambulance service provider furnishes emergency ambulance services to an insured but is not under contract with the insurer providing the insured’s policy/contract, the insurer must pay the ambulance service provider directly and promptly. Payment must occur even if the insured’s policy/contract prohibits benefit assignments, so long as the insured executes an assignment; if the insured cannot practically execute an assignment because the policy would otherwise prohibit it, payment is still required. The bill also provides that the provider is not considered paid if the insurer instead pays the insured for the emergency service, and it grants the provider a right of action against an insurer that fails to pay under this requirement.

Payment rate and billing consequences are set out: except for nonprofit corporations licensed to operate critical care ambulance services that do both ground and air transports, payment under the direct-pay rule must be at the rate established by the municipality where the patient was transported. The bill deems the provider paid in full once paid under these subsections and prohibits further billing of the insured for the ambulance service, except for amounts the insured remains responsible for under the policy (coinsurance, co-payments, or deductibles). The bill further clarifies that it does not limit an insured’s existing rights to ambulance coverage and does not create entitlement to ambulance coverage where the insured’s policy provides none.

AT A GLANCE

This bill requires health insurance issuers to accept complete prior authorization requests and issue standard decisions within 7 calendar days, and expedited decisions within 72 hours, after receipt.

FULL SUMMARY

The bill establishes a new Idaho “Prior Authorization Reform Act” within Title 41 (new Chapter 35) creating requirements governing how health insurance issuers and contracted utilization review organizations administer prior authorization for health benefit plans and stand-alone dental benefit plans.

Key changes and requirements include: (1) defining “prior authorization,” “complete prior authorization request,” “adverse determination,” and “expedited prior authorization request,” and setting chapter purposes (reduce unreasonable interference, prevent disruption of medical judgment, and require transparency); (2) requiring issuers to maintain and publicly post complete, current prior authorization service lists and access to clinical review criteria (including Idaho-specific effective/termination dates and, when applicable, access to standardized electronic submission processes); (3) requiring clinical review criteria to meet evidence- and standards-based consistency, accreditation alignment, and annual physician-directed updates; (4) establishing notice and timing rules for new or amended prior authorization requirements (generally 60 days advance notice to impacted enrollees and providers, with limited exceptions such as fraud/abuse findings, scarcity, FDA-authorized clinical trials, legal changes in <60 days, or removal of requirements); and (5) requiring issuers to report prior authorization approval/denial and appeal statistics to the Department of Insurance.

Operational process requirements include: (1) an electronic prior authorization API by January 1, 2027, conforming to CMS interoperability standards and supporting electronic request/response exchange; (2) rules for what makes a prior authorization request “complete,” including that minor clerical/technical errors not materially affecting adjudication cannot prevent “complete” status and that completeness is presumed unless additional specific information is requested within one business day; (3) standard prior authorization decisions within 7 calendar days after receipt of a complete request (with only reasonably necessary additional information and limit on requests for additional information to once per request absent materially new clinical information); (4) expedited decisions for urgent health care services within 72 hours after receipt of a complete expedited request (and requiring trained, appropriately licensed physician consultation mechanisms); and (5) adverse determination notices that must include reasons/evidence-based criteria and appeal rights, plus instructions for filing appeals, documentation needed for appeal, and the right to independent external review under Idaho law.

The bill also establishes appeal personnel and insurer and continuity rules: appeals must be peer reviewed by appropriately licensed and specialty-qualified professionals not directly involved in the adverse determination; insurers must periodically review prior authorization requirements and consider removal; issuers are limited in revoking or further restricting valid prior authorization approvals except for defined circumstances (fraud/abuse, unavailability/need for alternative service, FDA safety alerts or public health emergencies, changes required by accepted standards, legal changes within 60 days, or documented material clinical change); approvals have set validity periods (generally 6 months, with potential extension by agreement); recurring chronic-condition approvals must remain valid for the lesser of 12 months or the treatment length determined by the treating professional; and the bill requires continuity of prior approvals for at least the initial 90 days after an enrollee moves to a new health plan upon receipt of documentation, while allowing issuer review during that continuity window. Enforcement and administration are assigned primarily to the Idaho Department of Insurance, including cease-and-desist authority, plans of correction, and administrative fines up to $10,000 per violation for specified failures; there is no private right of action. The bill includes mandatory annual issuer reports (first due by June 1, 2027, and each June 1 thereafter) and creates penalties for knowing false prior authorization requests by routing findings to relevant licensing oversight and prosecuting authority. Finally, it creates a de minimis exemption allowing issuers with prior authorization use on fewer than 1% of claims to elect exemption via annual Department attestation, subject to Department verification and potential revocation. The act becomes effective January 1, 2027.

AT A GLANCE

This bill requires health carriers to reimburse providers’ reasonable documented administrative costs and complete clean-claim audits within 45 days after receiving documentation, or the claim automatically approves and pays with 10% interest.

FULL SUMMARY

The bill creates new Iowa requirements governing health carriers’ (1) auditing of clean claims and (2) standards of conduct for interactions with health care providers, and it adds new, detailed rules governing prior authorization decisions by utilization review organizations (UROs) and health carriers, including clinical- and peer-review requirements, appeal procedures, and exemptions.

For claim audits, the bill establishes a new section requiring that if a health carrier audits a clean claim, it must reimburse the provider’s reasonable documented administrative costs to respond to the audit. The bill also sets timelines: the carrier must notify the provider within 15 calendar days after selecting the clean claim for audit; must complete the audit and issue an adverse determination within 45 calendar days after receiving all requested documentation; and must process an appeal initiated by the provider no later than 30 calendar days after receipt of the audit determination, issuing a final determination within 14 calendar days after notice of the appeal. If the carrier violates the audit timelines, the clean claim is automatically approved and promptly paid with interest at 10% per annum. The audit rules do not apply to claims under active fraud investigation by a state or federal authority or to federal programs where audits are mandated by federal law. Violations by a health carrier are treated as unfair or deceptive acts and may trigger civil penalties; providers may recover litigation costs, including reasonable attorney fees.

For standards of conduct, the bill adds new prohibitions for health carriers, including: (a) no financial penalties, reimbursement reductions, administrative fees, or network termination based on a provider’s referral to or affiliation with out-of-network providers; (b) no interference with a provider’s staffing and referral decisions (except as otherwise provided by law); and (c) no offering/enforcing contract terms requiring provider negotiation opportunity and no enforcement of provisions that impose unreasonable or unconscionable obligations (such terms are void and unenforceable). Violations constitute unfair or deceptive acts, can lead to civil penalties, and allow providers to recover litigation costs, including attorney fees.

For prior authorizations, the bill creates a new URO/health-carrier “peer review” framework. It defines key terms (e.g., clinical peer, qualified reviewer, downgrade) and provides that a URO may deny or downgrade only if decisions are made by an appropriately credentialed qualified reviewer (physician) or clinical peer (non-physician), with the organization supplying: a written reasons statement, an appeals process explanation, and a written attestation containing specified credentials/identifiers and specialty or experience requirements. It also requires, on provider request after denial, a consultation within seven business days. If the denial/downgrade is appealed, the appeal must be handled by a qualified reviewer or clinical peer not involved in the initial determination and must consider relevant clinical records and submitted medical literature. Violations are deemed unfair/deceptive practices subject to civil penalties and allow providers to recover litigation costs, including attorney fees. Separately, the bill creates exemptions preventing a health carrier from requiring prior authorization or imposing additional utilization review for (1) certain cancer-related screening/preventive services recommended under updated NCCN oncology clinical practice guidelines, and (2) life-threatening conditions that develop or become evident while a covered person is receiving inpatient care, unless immediate assessment and treatment is provided. Applicability limits apply to health benefit plans delivered/issued/continued/renewed on or after January 1, 2027, and to certain pending prior authorization requests made before that date but not finally determined by it.

AT A GLANCE

This bill requires pharmacy benefits managers to reimburse eligible pharmacies for covered prescription drugs at national average drug acquisition cost plus the current Georgia Medicaid professional dispensing fee, excluding the calculation from effective-rate guarantees.

FULL SUMMARY

The bill establishes a new Georgia statutory requirement for pharmacy benefits managers (PBMs) regarding how “final reimbursement” must be calculated for “eligible pharmacies” for prescription drugs.

It creates new definitions in a newly added Code section: “affiliate pharmacy,” “eligible pharmacy,” “rural area,” and “rural pharmacy.” An “eligible pharmacy” is limited to pharmacies not owned by entities or natural persons with ownership/investment interests in more than 10 pharmacies. “Rural” is defined by county population under 50,000 using the 2020 (or any future) decennial census; “rural pharmacy” is an eligible pharmacy located in a rural area.

Beginning under the operative reimbursement rule, a PBM must ensure final reimbursement to an eligible pharmacy (after accounting for all fees, charges, adjustments, or reductions, including various fee categories) equals: the national average drug acquisition cost at the time the drug is dispensed plus a professional dispensing fee equal to the current Georgia Medicaid professional dispensing fee set by the Department of Community Health. If the national average drug acquisition cost is not available, the PBM must use the drug’s wholesale acquisition cost (defined by federal statute) as of the dispensing date plus the same Georgia Medicaid professional dispensing fee. The reimbursement calculated under this subsection must be excluded from any “effective rate guarantees” (defined as contractual provisions that allow PBMs to adjust reimbursement rates so overall averages reach a predetermined rate).

The new requirement does not apply to a state health plan (as defined in state law) and does not apply to Medicaid under Chapter 4 of Title 49, including Medicaid managed care programs administered through care management organizations. A separate carve-out allows PBMs to reimburse rural pharmacies above the required national-average-plus-dispensing-fee amount, but not for “affiliate, mail-order, and specialty pharmacies.” The bill takes effect July 1, 2027, and repeals conflicting laws.

AT A GLANCE

This bill requires Oregon health insurers that use AI or automated technology in utilization review to downcode claims to give providers written notice within two business days after the insurer makes payment intended to satisfy the claim.

FULL SUMMARY

The bill requires Oregon health insurers that conduct utilization review (or have utilization review provided on their behalf) to give health care providers specific written notice when the insurer uses artificial intelligence (AI), algorithms, or other automated technology to automatically “downcode” a claim for reimbursement.

Specifically, if AI/algorithm/software is used in utilization review to automatically downcode a claim, the insurer must provide the provider a written notice no later than two business days after the date payment intended to satisfy the claim is made. The notice must disclose the use of the technology, state the specific reason for the downcoding, and describe the insurer’s applicable appeals process and the time limits for requesting an appeal. If the downcoding is based on policy/certificate terms or a bill coding policy, the notice must cite the specific language used.

In addition, the bill amends ORS 743B.423 to make a provider eligible for a timely appeal when a claim is downcoded using AI/automated technology. The appeals process must be consistent with the process for requesting additional payment from a health insurer under ORS 743B.453. The bill also defines “downcode a claim” within ORS 743B.423 as changing a claim’s billing code to one with a lower reimbursement rate than the code in the original claim.

Applicability: the amendments apply to health benefit plans issued, renewed, or extended on or after the effective date of the 2026 Act.

AT A GLANCE

This bill requires hospitals to provide patients with written, electronic, and posted payment-assistance notices and make a pre-collection reasonable-effort notification before collection actions.

FULL SUMMARY

The bill makes two main sets of insurance-related changes effective July 1, 2026. First, it expands hospital requirements in Indiana Code IC 16-21-9.5 by defining “collection action” and “payment assistance program,” and by creating a new hospital chapter requiring notice, signage, and electronic availability of payment assistance options (including charity care, financial assistance, and other payment plans). Hospitals must provide written notice of their payment assistance programs to patients (or representatives) during registration/intake, at discharge, and with the initial billing statement; the notice must include available program descriptions, eligibility criteria, application instructions, and contact information. Hospitals must also post conspicuous signage in registration areas and emergency departments, provide information electronically through any patient portal, and—before starting a collection action—make a reasonable effort to notify the individual and provide an application form. Nonprofit hospitals must annually report compliance in their community benefits plan report, and the state department may adopt rules and impose civil penalties up to $1,000 per violation, deposited in the state general fund.

Second, the bill creates new limits and process protections concerning “downcoding” of health benefits claims by insurers and health maintenance organizations (HMOs) under new IC 27-1-52 (effective July 1, 2026). The new chapter defines key terms (e.g., “downcode,” “health benefits claim,” “insurer/health maintenance organization,” and CARC/RARC) and generally prohibits practices that would prevent providers from submitting claims for actual services and collecting reimbursement for actual services performed. It prohibits insurers from using automated processes/system/tools (including AI) as the sole basis to downcode a medically necessary claim without review of the covered individual’s medical record by an insurer employee/contractor, and prohibits providers from submitting claims using automated tools without review by a provider or other claim-preparer. Insurers must disclose when AI is used to make adverse prior authorization determinations or to downcode; insurers may not downcode solely based on diagnosis codes; and if downcoding occurs, insurers must notify providers with appropriate CARC and RARC, provide the specific clinical reason and clinical criteria reference, list original and revised service codes and payment amounts, and include a notice of appeal rights. Providers must be afforded an appeal process with a submission timeline of at least 180 days and the ability to appeal in batches of substantially similar downcoding issues. The chapter also prohibits targeted/discriminatory downcoding against providers treating complex or chronic conditions and directs the department to adopt rules to implement it.

In addition to these new chapters, the bill makes related changes to existing claims adjustment and recoupment timing rules for both accident and sickness insurers and HMOs. For CPT code reimbursement rates, it adds restrictions that prevent retroactive reimbursement rate reductions for CPT codes and require at least 60 days’ written notice (mail/e-mail plus website posting) before prospectively reducing CPT reimbursement rates (for accident and sickness insurers and for HMOs). It also amends the existing insurer and HMO overpayment/recoupment and audit/correction timing limits by extending the referenced time periods (adding a “one hundred eighty (180) days” component to multiple thresholds). Finally, it adds new provisions in both the insurer and HMO chapters addressing recoupment due to coordination-of-benefits errors by allowing providers to submit claims to the appropriate insurer/HMO for the same services, while generally requiring submission within 90 days after recoupment (with documentation requirements for the original submission and the recoupment due to coordination-of-benefits errors, and allowing insurers/HMOs to grant more time). It includes applicability provisions limiting the new downcoding and rate/claim-adjustment protections to policies issued/renewed after specified dates, and it exempts Medicaid.

AT A GLANCE

This bill establishes the Georgia Medicare for All Act as a universal, single-payer program for all Georgia residents and requires the program to be developed and implemented by no later than July 1, 2029.

FULL SUMMARY

The bill establishes the “Georgia Medicare for All Act” within Georgia’s public assistance law to create a universal, single-payer healthcare program for all Georgia residents, with a healthcare cost-control system and a supporting “Georgia Medicare for All Trust Fund.” It creates the Georgia Medicare for All Board (an independent public entity) to implement, direct, administer, and maintain the program, hire an executive director, and adopt rules for program operations. It also establishes four public advisory committees (general public advisory; Long-Term Care; State Health Benefit Plans; Workers’ Compensation), including specified membership structures, appointment processes, meeting requirements, and restrictions on use of nonpublic information.

The bill requires program development and implementation by no later than July 1, 2029, with a transition period and implementation period defined for special eligibility/financing and enrollment. It sets program governance responsibilities, including contracting authority, litigation authority, acceptance of grants and donations, information sharing with state agencies (subject to confidentiality), and setting transition/implementation dates. It restricts insurers during the transition/implementation framework by prohibiting insurers from offering benefits or covering services that the program covers for residents, while allowing other limited offerings (e.g., for nonresidents or during the transition period). It also provides for consumer choice and participation rules for healthcare organizations (nonprofit or governmental) and participating healthcare providers, including provider qualification standards and procedures for out-of-state services when medically necessary.

The bill defines covered benefits broadly and requires comprehensive coverage, including specified medical and ancillary services and expanded inclusions such as language interpretation, community care where appropriate under Olmstead, reproductive healthcare, and gender-affirming care; it also requires coverage of services required by specified federal and Georgia benefit authorities (PeachCare, Medicaid, Medicare, state employee/public employee health benefits, and ACA essential health benefits as of Jan. 1, 2026). Members are automatically enrolled if they are Georgia residents (with disenrollment/disqualification procedures and appeals), and the bill prohibits member cost-sharing for covered benefits (no fees/premiums/copayments/coinsurance/deductibles). Care coordination is required through approved care coordinators (who may be individuals or entities in specified categories), includes administrative tracking and record-keeping complying with privacy and retention requirements, and is tied to reimbursement rules (providers must be reimbursed only when a member is enrolled with a care coordinator).

The bill requires data collection and transparency measures (inpatient discharge, emergency/ambulatory surgery, and hospital financial data), submission to the Georgia All-Payer Claims Database, and public health research/aggregation activities using program data. It prohibits law enforcement from using program money/property/equipment/facilities/personnel or program information to investigate or enforce criminal, civil, or administrative violations or certain federal registration requirements based on protected characteristics. It creates the trust fund as a perpetual nonlapsing funding source, managed by the State Treasurer as custodian with disbursements only by written board direction.

Separately, the bill includes major reproductive freedom changes: it repeals and replaces Georgia’s “Woman’s Right to Know Act” with a “Reproductive Freedom Act,” establishes broad statutory rights to choose abortion, choose/refuse contraception or sterilization, and restricts state/local interference including bans on arrest or penalties for obtaining/assisting abortions when in compliance with the chapter. It authorizes abortion by healthcare professionals within lawful scope, provides anti-discrimination protections, and creates civil enforcement for injunctive relief with possible attorney’s fees/costs. It also repeals existing prohibitions on gender dysphoria-related treatments for minors by (i) repealing Code Section 31-7-3.5, (ii) revising penal institution funding/treatment restrictions by limiting prohibited treatments to narrower categories with specific allowed exceptions, (iii) repealing a 2023 act addressing gender dysphoria procedures in hospitals, and (iv) repealing reserved provisions in professional licensing statutes tied to those treatments.

Conforming changes include revising other Georgia code provisions that reference “abortion,” repealing and reserving certain abortion-related criminal articles, adjusting parental consent/notice statutes for minors in line with the new reproductive freedom definitions and framework, modifying child support and dependent determinations in specified contexts, and adding a Medicaid-related provision requiring the Department of Community Health to provide payment for abortion and abortion-related services for medical assistance recipients as defined by the cited Medicaid eligibility statute. Effectiveness is contingent for Part II: it takes effect only upon a specific line-item appropriation for the act’s purposes; Parts I, III, IV, V, and VI take effect upon governor approval or becoming law without approval.

AT A GLANCE

This bill requires out-of-network freestanding emergency rooms to accept a health plan’s in-network allowed amount for covered emergency services as payment in full and bars billing covered persons above it.

FULL SUMMARY

The bill establishes a new “Emergency Care Affordability Act” within Title 41, creating insurance requirements to protect covered persons from high-cost billing for emergency services provided by out-of-network freestanding emergency rooms and out-of-network providers.

It defines key terms including “allowed amount,” “emergency medical condition,” “emergency services,” and—critically—“freestanding emergency room” (a 24-hour, physically separate facility that principally provides unscheduled emergency services and participates in the federal independent dispute resolution process; exclusions include critical access hospitals and certain hospital- and physician-owned facilities). It also defines “out-of-network provider/facility,” including affiliates and billing entities that submit or attempt to submit claims on their behalf.

For covered emergency services, an out-of-network freestanding emergency room must accept the health benefit plan’s “allowed amount” for the same specialty/type in-network service in the same geographic area as payment in full, and may not bill the covered person for amounts above that allowed amount (regardless of billing entity, coding modifiers, or use of affiliated third parties). The covered person’s cost-sharing must be calculated using the plan’s in-network benefit design; the plan must pay the provider directly (minus covered-person cost sharing) without regard to beneficiary assignment or similar agreements. Any contract or consent allowing excess billing/balance billing for covered emergency services is void and unenforceable.

The bill further requires specified disclosure when an out-of-network freestanding emergency room furnishing emergency services is not enrolled in Medicare, Medicaid, or TRICARE: a plain-language notice (given as soon as practicable after the medical screening exam, only when the patient is conscious/oriented/capable and without interfering with stabilization) stating the facility’s nonparticipation and that the covered person may be personally responsible for some/all charges. Failure to provide the required disclosure creates a rebuttable presumption the covered person was not informed and, absent contemporaneous compliance documentation, bars the facility from billing/collecting/seeking reimbursement for emergency-services charges, rendering violative bills/invoices/collection attempts void. It adds rules for self-funded plans: the chapter applies to self-funded health plans only if they elect to participate by annual notice to the Idaho Department of Insurance and the election applies for the plan year; the director must publish an annual list of participating self-funded plans. Enforcement includes attorney’s fees and costs for covered persons or plans to challenge violations, voiding any violative billing by out-of-network facilities and affiliated billing entities, authorizing the director (upon written request) to inquire with the patient’s health benefit plan to verify payment consistency, and treating each attempt to bill/collect in violation as a separate violation. The act takes effect July 1, 2026, and an emergency clause makes it effective that date.

AT A GLANCE

This bill establishes an emergency medicine study committee in Arizona to review and assess emergency medical services delivery and capacity and to report findings by December 31, 2026 and annually thereafter.

FULL SUMMARY

The bill establishes an “emergency medicine study committee” to review and assess the state of emergency medical services and emergency medicine delivery in Arizona, including barriers and sustainability.

It creates a committee with specified membership: three House members appointed by the Speaker (no more than two from the same political party, with the Speaker designating a chairperson); three Senate members appointed by the President of the Senate (no more than two from the same political party); the Director of the Arizona Department of Health Services (or designee); two emergency department operators (appointed by the Speaker and separated by county population threshold of under 500,000 vs. 500,000 or more); three licensed physicians (appointed by the President of the Senate and allocated across emergency medicine in under-500,000 and 500,000+ counties, plus a medical director for an emergency medical services agency); one emergency-medicine registered nurse or nurse practitioner appointed by the Speaker; and two pre-hospital emergency medical services providers (one appointed by the Speaker for under-500,000 counties and one appointed by the President of the Senate for 500,000+ counties).

The committee’s duties include: (1) reviewing the delivery of the emergency medical services system and obstacles to its delivery and sustainability; (2) analyzing emergency medicine capacity, including rural/urban adequacy and factors affecting EMS delivery; (3) reviewing how uncompensated care affects the financial viability of emergency medicine practice; (4) identifying factors affecting the stability of entities delivering emergency medicine; and (5) soliciting input from patients, health care providers, and stakeholders regarding service delivery and financial viability. The committee may hold public hearings, conduct fact-finding tours, request data from the Department of Health Services, and take testimony. The Legislature and the Department of Health Services must provide staff and support. Members receive no compensation but may be reimbursed for expenses under Arizona law.

The committee must submit reports on or before December 31, 2026 and annually thereafter to the Governor, the President of the Senate, and the Speaker of the House, and provide a copy to the Secretary of State. The committee is repealed from and after June 30, 2029 (sunset of the committee’s existence and operations).

AT A GLANCE

This bill requires VHDHP health plan companies to pay emergency-room and ambulance charges within 15 days of receiving notice that an enrollee has not paid them within 30 days.

FULL SUMMARY

The bill establishes definitions and a new prompt-payment obligation tied to very high deductible health plans (VHDHPs) for hospital emergency room and ambulance charges that remain unpaid when an enrollee has not yet met the annual deductible.

Effective August 1, 2026, it amends Minnesota law to define “VHDHP” as a high deductible health plan with an annual maximum out-of-pocket expense exceeding $3,000 for individual coverage or $6,000 for family coverage. It also adds a new statutory subdivision requiring payment of emergency and ambulance charges under specified conditions.

For enrollees in plans meeting the VHDHP definition, and for the health plan company that issues such plans, the new requirement applies when the enrollee incurs charges for hospital emergency room care or ambulance service that are not payable at the time because the annual deductible has not been satisfied. In that situation, the VHDHP must require the health plan company to pay those charges directly to the hospital or ambulance service licensee within 15 days after receiving notice from the licensee that the enrollee has not paid the charges within 30 days after the date of treatment.

The bill permits the health plan company to seek reimbursement from the enrollee for payments it made, but requires the company’s collection procedures to comply with the same restrictions that would apply to the health care provider when collecting from the patient. The added provisions also prohibit the health plan company from canceling, terminating, suspending, nonrenewing, or otherwise limiting or reducing an enrollee’s (or the enrollee’s family’s) coverage as a collection penalty or as a consequence of failure to reimburse the health plan company for these payments, and require the provider/licensee to inform the health plan company in writing of any special collection restrictions applicable to the provider.

AT A GLANCE

This bill requires HMOs to pay noncontract providers within 30 days after receiving a claim and sets minimum reimbursement rates for covered services delivered to HMO enrollees.

FULL SUMMARY

The bill requires health maintenance organizations (HMOs) to pay certain nonparticipating (out-of-contract) health care providers within 30 days after receiving a claim and sets specific minimum reimbursement rates for covered services delivered to HMO enrollees by providers without a written contract.

For noncontract hospital services, the HMO must pay the rate approved by the Health Services Cost Review Commission. For trauma care, the bill sets a minimum payment standard for trauma physicians as the greater of (1) 140% of the Medicare rate for the same service to a similarly licensed provider, or (2) the HMO’s January 1, 2001 rate in the same geographic area, with both standards applying to the same covered service to similarly licensed providers. For other noncontract providers, reimbursement must be at least the greater of specified Medicare-inflated thresholds and/or Medicare-based thresholds: for evaluation and management services, no less than either (A) 125% of the HMO’s average contracted rate as of January 31, 2019 (rather than the previously referenced “January 1 of the previous calendar year”), inflated by the change in the Medicare Economic Index from 2019 to the current year, or (B) 140% of the Medicare rate as of August 1, 2008 inflated by the Medicare Economic Index from 2008 to the current year; and for services that are not evaluation and management services, no less than 125% of the HMO’s average contracted rate as of January 31, 2019 inflated by the Medicare Economic Index from 2019 to the current year.

The bill also clarifies how HMOs calculate the “average rate” for similarly licensed contracted providers: it requires summing the contracted rate across all occurrences of the relevant Current Procedural Terminology (CPT) code and dividing by the total number of occurrences. It maintains disclosure rights for noncontract providers by requiring HMOs, on request, to disclose the reimbursement rate required under the trauma provider and nontrauma provider minimum-payment provisions.

Beyond payment rules, the bill retains and/or adjusts operational and enforcement mechanisms applicable under the same section: HMOs may require trauma physicians to submit adjunct claims documentation and include an HMO-assigned provider number (with the HMO required to assign a provider number on request). It preserves restrictions on HMOs requiring referral or preauthorization for covered trauma services delivered by a trauma physician. It also maintains provider enforcement through complaints to the Maryland Insurance Administration or civil actions in court, attorney-fee awards when the provider’s complaint is sustained, annual compliance review and reporting by the Maryland Health Care Commission, enforcement authority for the Maryland Insurance Administration, and a civil penalty cap (up to $5,000) for violations that reflect a general business practice. The act takes effect October 1, 2026.

AT A GLANCE

This bill requires health carriers to cover and reimburse out-of-network emergency services to eligible covered persons, limits providers to plan cost sharing, and sets 60-day claim and reimbursement deadlines.

FULL SUMMARY

The bill creates a new Iowa statutory section, 514C.16A, establishing required insurance/health-plan coverage and a payment-and-dispute process for certain out-of-network emergency services. It defines key terms including “out-of-network provider,” “participating facility,” “emergency medical condition,” “emergency services,” “complicating factor,” “cost sharing,” and “arbitrator list” (a commissioner-approved list of arbitrators), and it requires coverage by a policy/contract/plan for services furnished by an out-of-network provider when the services are emergency services or when provided at a participating facility and the covered person could not receive equivalent services from a participating provider.

Under the new section, an out-of-network provider must submit a claim to the covered person’s health carrier no later than 60 calendar days after providing the services. Within 60 calendar days after receiving the claim, the health carrier must reimburse the out-of-network provider the greater of (1) the median amount that would have been paid to a participating provider in the same specialty for the same services (excluding cost sharing), or (2) 150% of the most recently published Medicare fee schedule amount for the service (excluding cost sharing). The bill prohibits the out-of-network provider from billing, attempting to collect from, or collecting from the covered person any amount beyond the cost sharing required by the covered person’s health benefit plan.

For out-of-network services involving a “complicating factor,” the provider may request additional reimbursement by submitting an initial claim that includes medical records and clinical documentation supporting the complicating factor and justifying the additional reimbursement. After receiving a claim for additional reimbursement, the carrier must, within 30 calendar days, either pay an additional amount equal to 25% of the initial-claim reimbursement or issue a denial letter explaining the denial basis. If denied, the provider may request binding arbitration with the insurance commissioner; the commissioner must notify both parties within 30 calendar days whether the request is accepted. The carrier then submits documentation within 30 calendar days reconfirming the denial or offering an alternative payment for arbitration consideration. The parties select an arbitrator from the commissioner’s arbitrator list, arbitration documentation is submitted, the arbitrator issues a written decision within 45 calendar days, arbitration costs are split equally between the carrier and provider, and the arbitrator considers specified documentation and the complicating factor.

The coverage/payment requirements apply to specified classes of third-party payment-provider contracts, policies, or plans delivered, issued, continued, or renewed in Iowa on or after January 1, 2027, including certain accident and sickness insurance, hospital/medical service contracts, health maintenance organization contracts, and public employee plans. The bill exempts specified specialized coverage types (e.g., accident-only, specified disease, short-term/hospital confinement indemnity, credit/dental/vision, Medicare supplement, long-term care, disability income, liability/worker’s compensation-related supplemental coverage, and automobile medical payment insurance) from the section’s requirements, and it authorizes the commissioner of insurance to adopt rules to administer the section. It also expressly allows private negotiation agreements that result in reimbursement greater than what the section requires.

AT A GLANCE

This bill requires insurers and managed care organizations to treat certified registered nurse anesthetists equivalently to physicians for participation, coverage, and payment when acting within licensed scope, and mandates NPI reporting on claims.

FULL SUMMARY

The bill establishes requirements across multiple Massachusetts health insurance and health plan structures that certified registered nurse anesthetists (CRNAs) be treated equivalently to physicians for purposes of participation, coverage, and payment when the CRNA is acting within the scope of practice under licensure/certification. It also requires that payment claims identify the National Provider Identifier (NPI) of the physician or CRNA who provided the service.

It amends Chapter 32A to add new Section 34 prohibiting the Commonwealth’s insurance commission from distinguishing between physicians licensed under Chapter 112 and CRNAs authorized under Chapter 112, Section 80B for participation/coverage/payment, while allowing varying reimbursement rates only if they rely on quality/performance measures that are the same for both provider types. It further requires that the commission reimburse contracted CRNAs at not less than the “allowed amount” it would reimburse for the same service when provided by a contracted physician, and bars reducing physician reimbursement to comply with this CRNA parity requirement.

The bill applies the same functional parity framework to Medicaid-managed care (Chapter 118E, added Section 83), and to private insurance arrangements under Chapter 175 (added Section 108O), Chapter 176A (added Section 39), Chapter 176B (adds CRNA-related definitions, removes “certified registered nurse anesthetist or” from Section 4T), adds a CRNA parity/reimbursement section (added Section 26), and amends Chapter 176G to define CRNAs, add CRNA parity/payment rules (added Sections 34 and 35), and clarify that physician authorization/involvement requirements for anesthesia reimbursement/coverage can be satisfied by a CRNA practicing under Section 80B. It also extends CRNA parity to preferred provider contracts and arrangements under Chapter 176I (added Section 14), requiring equivalent participation/coverage/payment treatment, NPI identification on claims, and not-less-than reimbursement with no physician pay reduction to achieve compliance.

AT A GLANCE

This bill requires Massachusetts health care carriers to reimburse providers at no less than 65% of qualifying unpaid cost-sharing amounts that remain uncollected after reasonable collection efforts.

FULL SUMMARY

The bill establishes a new reimbursement obligation for Massachusetts health care carriers regarding “uncollected” patient cost-sharing amounts (co-payments, co-insurance, and deductibles) that remain unpaid after specified provider collection efforts. It adds Chapter 176O, Section 7A, requiring carriers to reimburse health care providers at no less than 65% of each qualifying unpaid co-payment/co-insurance/deductible amount that is not collected after reasonable efforts.

Section 7A defines “co-payment” as a fixed dollar amount owed under a health benefit plan; “co-insurance” as a percentage of the allowed amount (after any co-payment); and “deductible” as a specific dollar amount owed before the plan’s obligation begins (excluding any portion of premiums). The bill deems reimbursement for qualifying unpaid amounts as recovery of an “uncollectible bad debt,” and permits providers to request reimbursement if (i) the claim derives from unpaid cost-sharing amounts under the insured’s plan, (ii) each claim is at least $250 and reflects a unique covered service for the insured, (iii) the provider made reasonable collection efforts with documentation, including that the claim is not subject to an ongoing payment plan for more than 120 days from the date the first bill was mailed, (iv) the provider submits an aggregate reimbursement request on or before May 1 for claims meeting criteria in the prior calendar year with specified documentation (insured identifiers, date of service, amounts collected, and contact details), (v) the carrier may audit eligibility/coverage and the provider’s collection-effort documentation, must complete audits and dispute notifications within 120 days of receipt, and pays 65% of “undisputed” amounts within 120 days, and (vi) any amounts recovered by the provider after carrier reimbursement must be offset against future submissions.

The bill also prevents a carrier from prohibiting providers from collecting the insured’s cost-sharing at the time of service. It requires the Division of Insurance to promulgate regulations within 90 days of the act’s effective date consistent with CMS rules for reasonable collection efforts; if the division does not issue regulations in time, Section 7A is self-implementing and carriers must use the CMS bad-debt collection-efforts process documented in the most recent Medicare Provider Reimbursement Manual (CMS Pub. 15-1 and 15-2 (HIM-15)) as in effect within 90 days of the act’s effective date. Finally, it requires each carrier to provide an annual public report (posted on the division’s website) identifying the total number and amount of reimbursed and denied uncollected co-payments, co-insurance, and deductibles.

AT A GLANCE

This bill requires HMOs to reimburse noncontracted trauma physicians at the greater of 140% of the applicable Medicare rate or the CMS-published January 1, 2001 rate for similarly licensed providers.

FULL SUMMARY

The bill revises the payment obligations of health maintenance organizations (HMOs) for covered services provided to enrollees by health care providers that are not under written contract with the HMO, specifically altering the reimbursement-rate requirements and the formulas used to determine them.

For noncontracted trauma care, the HMO must continue to pay a trauma physician (for trauma rendered to a trauma patient in a trauma center) at the greater of: (1) 140% of the Medicare program rate for the same covered service to a similarly licensed provider, or (2) the HMO’s rate as of January 1, 2001 (as published by CMS) for the same covered service to a similarly licensed provider.

For other noncontracted providers, the bill changes the “evaluation and management service” reimbursement floor and the benchmark date used for inflation calculations. Instead of using the HMO’s average rate paid as of “January 1 of the previous calendar year,” it uses the average rate paid as of “January 31, 2019.” For evaluation and management services, the HMO must pay no less than the greater of (A) 125% of that January 31, 2019 average rate, inflated by the change in the Medicare Economic Index from 2019 to the current year, or (B) 140% of the Medicare rate as of August 1, 2008 inflated by the change in the Medicare Economic Index from 2008 to the current year. For non-evaluation-and-management services, the HMO must pay no less than 125% of the January 31, 2019 average rate (inflated by the Medicare Economic Index change from 2019 to the current year).

An HMO must still disclose, on request of a noncontracted provider, the reimbursement rate required under the noncontracted-provider provisions, and it must continue using a defined method to calculate average contracted rates by summing contracted Current Procedural Terminology (CPT) code rates and dividing by total occurrences. The bill also retains enforcement and administration provisions, including provider enforcement through complaints to the Maryland Insurance Administration or civil action, annual compliance review by the Maryland Health Care Commission, regulatory implementation by the Maryland Insurance Administration, and civil penalties for HMO violations. The Act takes effect October 1, 2026.

AT A GLANCE

This bill authorizes the Massachusetts Senate committee on Health Care Financing to investigate and study numerous pending Senate health care financing documents and report its findings through the normal legislative process.

FULL SUMMARY

The order authorizes the Massachusetts Senate committee on Health Care Financing to conduct an investigation and study of numerous pending Senate documents numbered 111, 154, 168, 465, 472, 622, 679, 683, 692, 694, 695, 696, 698, 709, 712, 715, 716, 718, 724, 726, 728, 742, 756, 758, 759, 774, 776, 777, 778, 791, 792, 796, 798, 802, 805, 806, 809, 814, 818, 822, 823, 824, 827, 832, 839, 840, 841, 844, 845, 846, 847, 848, 849, 852, 853, 856, 859, 860, 861, 863, 864, 865, 871, 873, 874, 877, 878, 879, 880, 881, 883, 884, 885, 886, 888, 890, 891, 892, 893, 894, 896, 897, 898, 899, 902, 903, 905, 906, 907, 908, 910, 911, 912, 913, 914, 915, 916, 917, 1042, 1289, 1362, 1388, 1411, 1418, 1480, 1481, 1488, 1505, 1511, 1514, 1515, 1535, 1538, 1551, 1554, 1554, 1565, 1578, 1582, 1583, 1586, 1601, 1602, 1621, 1791, 1792, 1847, 2587, 2599, and 2600, all described as relating to health care financing matters.

The order directs that the committee “make an investigation and study” of the listed Senate documents and report back through the normal legislative process; the text does not specify substantive policy changes, new regulatory requirements, or amendments to existing statutes.

The accompanying committee referral text (pages 1–6) lists the subject areas covered by the referenced Senate documents (e.g., behavioral health access, Medicaid/health safety net eligibility, health insurance coverage rules, hospital and long-term care issues, workforce and public health initiatives, and health care cost and transparency measures), but the operative action taken in this document is the authorization to study/investigate those proposals collectively.

AT A GLANCE

This bill requires the New Mexico Health Care Authority to set Medicaid reimbursement codes for qualifying independent reference laboratory toxicology services and reimburse them based on specified fee-for-service rates, conditioned on medical necessity and evidence-based protocol performance.

FULL SUMMARY

The bill establishes a Medicaid reimbursement framework for toxicology services furnished by independent reference laboratories.

It creates new statutory requirements in a new Public Assistance Act section requiring the New Mexico Health Care Authority to (1) set Medicaid reimbursement codes for qualifying independent reference laboratory toxicology services, (2) reimburse those services at an amount equal to the average Medicaid fee-for-service rate schedule for specified Healthcare Common Procedure Coding System (HCPCS) codes used for billing definitive drug testing, and (3) condition reimbursement on medical necessity (determined by the treating health care provider) and on performance consistent with evidence-based clinical protocols adopted by the authority and aligned with behavioral health or substance use disorder treatment standards. The authority must promulgate rules establishing the reimbursement protocols, using nationally accepted clinical guidance as part of the rulemaking.

The bill also defines key terms used for eligibility and reimbursement, including “financially affiliated” and “independent reference laboratory,” and defines “toxicology services.” The “independent reference laboratory” definition includes operational and in-state physical presence requirements, federal and accreditation/licensure conditions, Medicaid provider enrollment, independence from certain other entities (no ownership/control/financial affiliation with hospitals, physician practices/groups, managed care organizations, or insurers), and requirements that specified revenue-cycle and billing activities occur physically within New Mexico. It further authorizes the authority to request tax filings and certificates of good standing to verify eligibility for reimbursement.

Finally, the bill appropriates $100,000 from the general fund to the Health Care Authority for fiscal year 2027 to administer Medicaid reimbursement for toxicology services by independent reference laboratories, with any unexpended balance reverting to the general fund. The effective date is July 1, 2026.

The California Health Care Quality and Affordability Act establishes a framework for analyzing health care costs and setting statewide cost targets for various health care entities, including providers, integrated delivery systems, and pharmaceutical companies. The legislation aims to address the rising costs of health care by implementing measures that promote affordability and quality.

Key provisions of the act include the adjustment of cost targets based on projected increases in prescription drug costs and organized labor costs for nonsupervisory employees. This approach is designed to ensure that health care entities can manage their expenditures while adhering to the established targets, which will be informed by historical cost data, economic indicators, and demographic changes.

The act emphasizes the importance of collaboration among health care entities to minimize fragmentation within the system. By establishing specific targets for different health care sectors, the legislation encourages cooperation and transparency in cost management.

Overall, the act seeks to create a more sustainable health care system in California by promoting accountability and informed decision-making regarding health care spending. Through comprehensive data analysis and stakeholder engagement, the legislation aims to enhance the quality and affordability of health care for all Californians.

AT A GLANCE

This bill requires the Health Care Authority to establish Medicaid reimbursement codes for eligible independent reference laboratories and set reimbursement equal to the average Medicaid fee-for-service rate for specified HCPCS codes.

FULL SUMMARY

The bill establishes new Medicaid reimbursement requirements for toxicology services provided by independent reference laboratories, including how reimbursement rates are calculated, conditions for coverage (medical necessity and evidence-based protocols), and authority rulemaking on reimbursement protocols and testing frequency.

It creates a new section in the New Mexico Public Assistance Act requiring the Health Care Authority to establish Medicaid reimbursement codes for eligible independent reference laboratories and to set reimbursement equal to the average Medicaid fee-for-service rate schedule for specified HCPCS codes used for billing definitive drug testing. Reimbursement is tied to (1) treating-health-care-provider determination of medical necessity and (2) performance in accordance with evidence-based clinical protocols adopted by the authority that are consistent with applicable behavioral health or substance use disorder treatment standards. The bill also directs the authority to consider nationally accepted guidance (including American Society of Addiction Medicine recommendations) while developing reimbursement rules, describes example guidance on testing frequency (weekly at initiation unless documentation supports otherwise; monthly in stable recovery unless provider assessment indicates otherwise; and randomized testing when feasible/appropriate), and authorizes the authority to request documentation (tax filings and certificates of good standing) to verify laboratory eligibility.

The bill defines key terms for the new section, including “financially affiliated,” “independent reference laboratory” (with criteria such as in-state facility and staffing, CLIA certification, CAP accreditation, Medicaid enrollment, no ownership/control/financial affiliation with specified entities, and in-state performance of billing/coding/claim submission/revenue-cycle activities; plus compliance with New Mexico gross receipts tax laws), “medicaid,” and “toxicology services” (laboratory testing of biological specimens for presence of drugs or alcohol). It clarifies that the section does not create a mandatory minimum or maximum frequency for reimbursement and does not restrict providers from ordering testing at a clinically necessary, documented frequency.

Finally, the bill appropriates $100,000 from the general fund to the Health Care Authority for fiscal year 2027 to administer Medicaid reimbursement for toxicology services provided by independent reference laboratories, with any unexpended balance reverting to the general fund, and sets an effective date of July 1, 2026.

AT A GLANCE

This bill requires Massachusetts health insurance carriers to reimburse eligible providers for qualifying unpaid co-payments, co-insurance, and deductibles at not less than 65% after reasonable collection efforts.

FULL SUMMARY

The bill creates a new statutory requirement in Massachusetts for certain health insurance carriers to reimburse health care providers for specified, uncollected patient cost-share amounts (co-payments, co-insurance, and deductibles) that become unpaid after the provider undertakes “reasonable collection efforts.” A carrier must reimburse a provider not less than 65% of each qualifying unpaid co-pay/co-insurance/deductible amount under the insured’s health benefit plan.

The statute defines key terms (co-payment as a fixed dollar amount; co-insurance as a percentage of the allowed amount after any co-payment; deductible as a specific dollar amount owed before the carrier’s obligation attaches, excluding premiums). It treats each qualifying unpaid co-pay/co-insurance/deductible amount as an “uncollectible bad debt,” but allows providers to request reimbursement only if multiple conditions are met, including that the amount is from an unpaid co-payment/co-insurance/deductible under the health benefit plan; each claim reflects a unique covered service per insured; each claim is at least $250; and the provider documents genuine, continuous attempts to contact the member and that the claim has remained partially or fully unpaid and not on an ongoing payment plan for more than 120 days from the first bill mailed (with documentation including dates and methods of contact). Providers must submit an aggregate annual request by May 1 for the prior calendar year with specified documentation (including insured identifiers, date of service, unpaid amount, amounts collected, and contact details), and the carrier may audit eligibility/coverage and reasonableness of efforts.

Carrier payment and dispute timing are also established: the carrier must complete any audit and notify the provider of disputes within 120 days of receipt; the carrier must pay 65% of undisputed amounts within 120 days. Amounts the provider collects after reimbursement must be recorded and reported as an offset to future submissions to that carrier. The bill also states that no carrier may prevent a provider from collecting any co-pay/co-insurance/deductible amount at the time of service.

The bill directs the Division (state insurance regulator) to promulgate regulations within 90 days of the act’s effective date consistent with federal Centers for Medicare & Medicaid Services rules on “reasonable collection efforts” for bad debt. If the division does not issue regulations, the reimbursement provisions are to operate using the CMS process documented in the most recent Medicare Provider Reimbursement Manual (CMS Pub. 15-1 and 15-2 (HIM-15)) applicable within 90 days of enactment. The division must require each carrier to submit an annual public report on the total number and amounts of reimbursed and denied uncollected co-payments/co-insurance/deductibles, and the report must be posted on the division’s website.

AT A GLANCE

This bill allows dually eligible Massachusetts residents to receive specialist and hospital services from any participating Medicare or MassHealth provider without network limitations, and it requires One Care and SCO plans to provide twelve-month continuity of care after contract termination.

FULL SUMMARY

The bill amends Massachusetts General Laws Chapter 118E, Section 9d by adding a new paragraph (r) (page 2) establishing that dually eligible individuals residing in Massachusetts may receive health care services from any specialist or hospital provider in the Commonwealth that participates in and is enrolled in Medicare or MassHealth, regardless of health plan or provider-network limitations, and subject to the other terms and conditions of the member’s benefit plan.

The new paragraph (r) (page 2) also provides a reimbursement rule when no existing contractual relationship exists between the health plan and the specialist or hospital provider: the provider must be reimbursed by the One Care or SCO plan at the Medicare or MassHealth fee-for-service amount for the services rendered, unless the plan and provider already have a contract agreement for the covered service or mutually agree to a different reimbursement amount.

The bill further amends Section 9d by adding paragraph (l) (page 3) requiring MassHealth to impose continuity-of-care protections on One Care and SCO plans and providers that terminate contracts covering services for One Care or SCO members. If a plan or provider terminates such a contract, affected members must be allowed to continue receiving their primary care, specialist, and inpatient or outpatient hospital services under the terms of the provider’s pre-existing contract for twelve months after the expiration of any continuity-of-care requirements that may follow the contractual termination.

During the twelve-month continuation period (page 3), plans are required to maintain all contractual terms and conditions that were in effect prior to the notice of termination being sent—including reimbursement—unless the plan and provider mutually agree to different terms. Plans and providers are prohibited from using the continuity provision to avoid good-faith efforts to negotiate new contractual arrangements (page 3).

AT A GLANCE

This bill requires the Group Insurance Commission, Medicaid managed care entities, and contracted insurers to cover all medically necessary ostomy- and fistula-related supplies without requiring “non-medical” items.

FULL SUMMARY

The bill adds new requirements across Massachusetts health insurance and healthcare settings to improve coverage and continuity of access to ostomy care supplies and related fistula management. It inserts new provisions in Chapter 32A (Group Insurance Commission), Chapter 111 (acute-care hospitals), Chapter 112 (physician licensing/clinical prescribing rules), Chapter 118E (Medicaid managed care), and the major commercial insurance statutes (Chs. 175, 176A, 176B, and 176G), with largely parallel requirements.

For insureds under the Group Insurance Commission and for Medicaid managed care and contracted insurers/administrators (Chs. 32A and 118E), the respective commissions/division must provide coverage of all medical supplies for management of surgically created or spontaneous fistulas and supplies related to ostomy care, and may not require “non-medical” supplies as a condition of coverage. Each entity must make publicly available information about its ostomy-supply coverage. The bill also requires transfer of ostomy care information, patient history, and prescriptions to a new insurer within 72 hours when a person obtains new health insurance coverage, and prohibits delaying ostomy supply orders/shipments during the transition period.

Across the physician and pharmacy/supplier workflow, the bill requires that an ostomy-related prescription issued by a licensed physician be valid for at least 1 year without disruption. It allows physicians to prescribe ostomy supplies in quantities exceeding any legal/regulatory/insurance-policy limits when the physician determines it is necessary and expedient for patient care. It prohibits delaying fulfillment based on approval/appeal processes and requires ostomy suppliers to provide 1 month of advanced notice of prescription expiration to both patients and prescribers.

It also limits substitution (“non-medical switching”) of ostomy supply brands/products: suppliers must dispense as written and provide 1 month of advanced notice of intended substitution by mail, with the notice including samples of the proposed substitute for the patient to try; if the substitute fails to meet or exceed the quality of the original and compromises ostomy care, the patient may return to the original product or receive a product that matches the original quality. In addition, healthcare payers must reimburse ostomy supply suppliers at a rate not less than the Medicare reimbursement rate, and the bill requires acute-care hospitals performing ostomy surgery to employ and provide access to certified healthcare professionals specializing in ostomy care, including appropriate outpatient follow-up with such specialists.

The document presents a resolution urging Congress to empower state insurance regulators with authority over Medicare Advantage plans. It raises concerns about the absence of state oversight since the Medicare Modernization Act was enacted in 2003, which has resulted in aggressive and misleading marketing practices within the Medicare private plan marketplace.

Key issues highlighted include reports from state departments of insurance and consumer advocacy organizations regarding misrepresentations in the marketing of Medicare Advantage plans, particularly concerning provider networks and benefits. The resolution points out that aggressive sales tactics often target seniors and vulnerable adults, making it difficult for them to make informed decisions about their healthcare options.

The resolution advocates for Congress to acknowledge that states are better positioned to oversee Medicare plans and safeguard consumers from fraudulent practices, similar to their regulation of other health plans. It calls for legislation that would enable states to enforce their own marketing and consumer disclosure laws for Medicare plans.

AT A GLANCE

This bill requires Medicaid payments for services from federally designated rural emergency hospitals to be “subject to appropriation,” regardless of the beneficiary’s managed care enrollment status.

FULL SUMMARY

The bill changes Washington’s Medicaid hospital payment rules for certain rural hospitals by amending RCW 74.09.5225. It first revises the general rural critical access hospital payment framework to clarify that payments are based on allowable costs for rural hospitals certified as critical access hospitals, with an exception for hospitals participating in the Washington rural health access preservation pilot. It also caps any additional healthy options program payments to no more than the additional amounts paid under the same section for other medical assistance programs.

The bill updates the pilot participation and transition mechanics. It specifies that rural hospitals approved by the Department of Health to participate in critical access hospital payments that join the Washington rural health access preservation pilot (identified by the Office of Rural Health) may cease participation in critical access hospital associated payment methodologies and may renew participation at any time. It also reiterates the pilot’s conditions: goal-setting before hospitals join; optional participation; pre-entry notice to hospitals on how to end participation if the pilot is not working; and that pilot payments for eligible public health care service district services must use an alternative, value-based payment methodology funded (subject to appropriations) to sustain essential emergency and primary care services, adjusting payment based on quality/value rather than volume. Reporting duties remain (interim reporting by December 1, 2018; final reporting within six months after pilot conclusion), and pilot funds must support transition to the new payment methodology and not extend beyond an anticipated three-year pilot period.

The substantive change for payment terms is the addition of an express appropriation requirement for rural emergency hospital payments under subsection (4). Specifically, it requires that Medicaid payments for services provided by a rural hospital designated by the federal Centers for Medicare and Medicaid Services as a rural emergency hospital—regardless of a beneficiary’s managed care enrollment status—are “subject to appropriation.”

The bill also retains and restates existing enhanced payment rate conditions for certain rural hospitals (including sole community hospital certification, level III adult trauma designation, bed count threshold, and state/local ownership), plus related conditions that such enhanced rates are treated as the hospital’s Medicaid payment rate for other programs and that hospitals in the certified public expenditures program cannot receive the increased inpatient reimbursement rates.

AT A GLANCE

This bill requires health insurers to respond to hospital and physician prior-authorization requests within specified 48-hour or 24-hour deadlines and deem approvals when they fail to timely act.

FULL SUMMARY

The bill establishes the “New Jersey Respect for Physicians Act” and makes changes to the existing “Health Claims Authorization, Processing and Payment Act” relating to health-insurance prior authorization. It requires payers to respond to hospital or physician prior-authorization requests faster in most scenarios (reducing the outer response deadline from 15 days to 48 hours for inpatient requests expected to be received and for outpatient/other settings), while keeping the 24-hour deadline for requests involving patients already receiving inpatient services or care in an emergency department.

Under the revised authorization-timing rules, when additional information is needed, payers receive shorter additional periods to approve or deny: the additional maximum beyond receipt of the requested information is reduced from 15 days to 48 hours for inpatient and outpatient/other settings (while remaining capped at 24 hours for emergency-department/inpatient-in-progress situations). The bill also requires payers to notify the hospital/physician and identify specific needed information, and it retains deeming rules under which a failure to respond within required timeframes results in the physician/hospital request being deemed approved and the payer being responsible for payment for covered services delivered.

The bill retains/clarifies operational requirements, including that payers and hospitals must have appropriate staff available between 9 a.m. and 5 p.m., seven days a week, to respond within the established authorization timeframes, and that if a hospital/physician fails to respond to a payer’s request for additional information within 72 hours, the authorization request is deemed withdrawn. It also includes a requirement (in connection with certain prior authorization requests) that the payer make reasonable attempts to contact the hospital and physician by telephone to discuss the request within four hours of the request being made.

The bill takes effect immediately.

The document introduces a new section to chapter 41.05 RCW, establishing reimbursement requirements for health carriers and hospitals in Washington State, primarily impacting the healthcare industry, including health carriers, hospitals, and providers of primary care and behavioral health services.

Starting January 1, 2027, reimbursement for inpatient and outpatient hospital services will be capped at the lesser of billed charges, the contractor's contracted rate, or 200% of the Medicare reimbursement rate, with specialty hospitals treating children set at 350% of the Medicare rate. Rural hospitals designated as critical access or sole community hospitals are guaranteed at least 101% of allowable costs as defined by Medicare. For primary care services, reimbursement will not fall below 150% of the Medicare rate or the contractor's contracted rate. Adjustments to these limits will take effect on January 1, 2029, raising the caps to 190% for general hospitals and 300% for specialty hospitals treating children.

The legislation aims to enhance access to affordable healthcare services while regulating reimbursement rates for various healthcare providers. Additionally, it mandates that contractors provide cost and quality data for monitoring purposes, ensuring that premiums reflect the anticipated changes in reimbursement rates. A report analyzing the impacts of these changes on network access, enrollee costs, and state expenditures is required by December 31, 2030.

The legislation addresses health care workforce shortages intensified by the COVID-19 pandemic by ensuring that advanced practice registered nurses (APRNs) and physician assistants (PAs) are reimbursed at the same rate as physicians for the same services. This change is particularly important for health systems, clinics, and private practices, especially in underserved and rural areas.

Starting January 1, 2026, health carriers are required to reimburse APRNs and PAs at rates equal to those of physicians for primary care and behavioral health services. Additionally, any nonclaims-based payments made to physicians must also be available to APRNs and PAs for the same services, and reimbursement rates for physicians cannot be reduced to meet this requirement.

The legislation aims to promote equitable reimbursement practices within the health care industry, which could enhance access to care in various communities. By addressing these disparities, the law seeks to improve the overall health care landscape, particularly in areas facing workforce challenges.

The document outlines legislative changes in Washington State aimed at improving compensation for health care providers who are not employed by hospitals or their affiliates. These changes primarily impact individual practitioners, small clinics, and health carriers, ensuring that they receive fair compensation.

Starting January 1, 2026, health benefit plans must include compensation provisions that adjust annually based on the consumer price index for all urban consumers. This measure is designed to address the issue of stagnant compensation rates for health care providers, which have not kept pace with rising operational costs.

Overall, the legislation seeks to promote competition within the health care market and prevent further consolidation by ensuring that providers receive adequate compensation for their services.

AT A GLANCE

This bill requires insurers and contracted entities to cover medically necessary mental health services delivered in specified settings without preauthorization and to notify carriers within three business days after admission.

FULL SUMMARY

The bill establishes expanded insurance coverage requirements for “medically necessary mental health services” across multiple payer types (state group insurance under G.L. c. 32A; Medicaid managed care and related arrangements under G.L. c. 118E; commercial insurance products under G.L. c. 175, 176A, 176B, and 176G). In each amended provision, carriers and contracted entities must cover specified mental health services delivered in enumerated settings (including inpatient psychiatric facilities, community health/behavioral/mental health centers, hospital outpatient departments, outpatient substance use disorder providers, community-based acute treatment and intensive community-based acute treatment, crisis stabilization services, and youth crisis stabilization services) without requiring preauthorization; if a patient is admitted, facilities must notify the carrier within three business days (and services provided prior to notification must be covered), with notification limited to patient name, facility name, time of admission, diagnosis, and the initial treatment plan. Medical necessity is determined by the treating clinician in consultation with the patient and is recorded in the member/patient medical record.

It amends the Massachusetts mental health provider framework by (1) revising who qualifies as a “licensed mental health professional” in multiple statutes (G.L. c. 111 and parallel definitions in G.L. c. 175, 176A, 176B, 176G), broadening the enumerated categories and explicitly including additional licensed clinicians and supervised post-master’s clinical behavioral health trainees pursuing licensure under supervision; and (2) adjusting the definition of “Emergency services programs” under G.L. c. 175 to more clearly cover contracted acute-care hospital and community-based emergency behavioral health services, including specified 24/7 crisis assessment/intervention/stabilization delivered through mobile crisis intervention and adult/youth community crisis stabilization services. It also exempts certain Mental Illness (MIH) programs focused on behavioral health services from application and registration fees under G.L. c. 111O.

The bill also modifies facility planning and funding triggers for acute psychiatric services by inserting a new basis under G.L. c. 111 (s. 25C ½) that authorizes a health facility to make capital expenditures for development of acute psychiatric services (inpatient, community-based acute treatment, intensive community-based acute treatment, partial hospitalization programs, and crisis stabilization services) if the facility demonstrates a need for a Department of Mental Health license under the referenced chapter-19 provision.

Finally, it makes changes to Massachusetts civil commitment and restraints law in G.L. c. 123: it replaces the hospital application/admission restraint process sections (s. 12, s. 21, and s. 22) with updated text governing 3-day hospitalization applications, admission authority, required notices (including committee for public counsel services), emergency transport restraint limits, stricter rules on when restraint and seclusion may occur (including time limits, examination requirements, documentation/reporting, and review procedures for minors), and civil immunity for specified actors when acting in accordance with the chapter. It also requires prompt insurance reimbursement-related regulations: the Division of Insurance, in consultation with the Division of Medical Assistance, must promulgate regulations or guidance within 30 days to require carriers to reimburse acute care hospitals for emergency behavioral health services (including via telemedicine/electronic/telephonic consultation) at contractual rates no less than the prevailing MassHealth rate for behavioral health emergency department crisis evaluations, while stating additional reimbursement obligations for other emergency department-related medically necessary services and for inpatient placement delays; these behavioral health services are deemed medically necessary and cannot require prior authorization.

The proposed legislation amends New York's social services law to require Medicare and Medicaid managed care providers to cover out-of-network healthcare under specific conditions. This change primarily affects managed care providers and healthcare professionals.

Key provisions mandate that managed care providers approve a single patient agreement with a healthcare professional with whom the patient has a long-term relationship, defined as a treatment relationship of at least ninety days and a minimum of ten visits. The healthcare professional will be compensated at the managed care provider's in-network rates.

Coverage for these services will be included at the time of application for medical assistance or on any anniversary date of existing coverage, contingent upon evidence of eligibility. Coverage may also be subject to annual deductibles and co-insurance as determined by the commissioner of health.

The act is set to take effect on the ninetieth day after it becomes law.

The document outlines significant amendments to New York's public health law concerning the minimum wage for home care aides. Starting October 1, 2022, the minimum wage for these workers was increased by $2.00 above the applicable minimum wage. For 2024, the minimum wage will be set at $18.55 per hour in downstate areas and $17.55 per hour in the rest of the state. This will further increase to $19.10 and $18.10, respectively, from January 1, 2025, to April 1, 2025. After April 2, 2027, the minimum wage for home care aides will be at least 150% of the applicable statewide or regional minimum wage.

Additionally, the Commissioner will establish a regional minimum hourly base reimbursement rate for providers employing home care aides, which will account for the average costs associated with delivering direct services. Payments to providers must meet or exceed this established reimbursement rate, with annual adjustments made to reflect any changes in labor laws.

A study will also be conducted to explore the potential benefits of an expanded state earned income tax credit aimed at enhancing the home care aide workforce, with findings expected by December 31, 2026. These changes are designed to improve compensation and support for home care workers in New York, thereby positively impacting the home care industry.

The proposed legislation seeks to amend New York's social services law to protect Medicaid benefits for individuals with temporary protected status and those enrolled in the Deferred Action for Childhood Arrivals (DACA) program. This amendment ensures that these individuals will continue to receive Medicaid even if the federal government terminates their designations.

Key provisions of the legislation include the guarantee that Medicaid benefits for temporary protected status beneficiaries will not be canceled or suspended due to the termination of their country's designation. Additionally, individuals who were previously granted temporary protected status will remain eligible for Medicaid, provided they meet all other requirements except those related to immigration status.

The legislation also safeguards Medicaid benefits for individuals enrolled in DACA, ensuring their coverage remains intact regardless of any federal program termination. Furthermore, individuals who were formerly enrolled in DACA will be eligible for Medicaid, contingent on meeting all other requirements aside from immigration status.

The act is designed to take effect immediately upon passage, impacting healthcare providers and social services organizations that will need to adjust to the new eligibility criteria and benefits administration. The specific financial implications of these changes are not detailed in the text.

The 132nd Maine Legislature has proposed legislation to increase the MaineCare reimbursement rate for ambulance services to 140% of the average allowable reimbursement rate under Medicare. This change is intended to address critical funding issues identified by recent blue ribbon commissions, which have raised concerns about the financial viability of emergency medical services providers.

To support this initiative, the bill includes a transfer of $15,000,000 from the Department of Public Safety's Emergency Medical Services Stabilization and Sustainability Program to the Department of Health and Human Services. Additionally, there will be a one-time allocation of $7,300,000 from the Federal Expenditures Fund and $5,000,000 from Other Special Revenue Funds for the fiscal years 2025-26 and 2026-27.

The overall financial impact on the Department of Health and Human Services is projected to total $12,300,000 across all funds for the same period. The urgency of this funding increase is underscored by an emergency clause in the legislation, allowing it to take effect immediately upon approval to ensure the preservation of public health and safety.

The document outlines amendments to New York's insurance and social services laws, mandating that health insurance plans cover electrocardiograms (ECGs) for both adults and children who have received a coronavirus vaccine. This requirement applies regardless of any family history of heart disease, provided the ECG is ordered by a licensed healthcare professional in line with established clinical standards.

The healthcare and insurance industries will be directly impacted by this legislation, as insurance providers will need to revise their policies to include ECG coverage. Consequently, healthcare providers may experience an increase in ECG testing due to this new mandate.

While specific monetary impacts are not detailed, the requirement for insurance coverage of ECGs could lead to higher costs for insurance companies, potentially affecting premiums for policyholders. Additionally, healthcare providers may see changes in their revenue streams as a result of increased ECG testing.

Overall, the legislation aims to improve preventive healthcare measures for individuals vaccinated against coronavirus by ensuring they have access to essential cardiac evaluations.

The document outlines significant amendments to New York's public health and insurance laws, focusing on reimbursement for telehealth services through commercial and Medicaid channels. A permanent framework for these reimbursements is established, effective immediately and retroactive to April 1, 2022. Additionally, the amendments introduce two key programs: the Rural Healthcare Professional Loan Repayment Award Program and the Rural Healthcare Professional Tax Credit Program, both designed to support healthcare providers in underserved rural areas.

The Loan Repayment Awards can cover the total qualifying outstanding student loan debt of healthcare professionals, with awards distributed over five years. Meanwhile, the Tax Credit Program allows eligible healthcare professionals to claim a refundable tax credit based on their wages, with specific caps on the amounts that can be claimed annually and an aggregate limit on credits issued each year.

These initiatives primarily benefit healthcare professionals, including physicians, nurses, and mental health practitioners, as well as healthcare facilities located in rural areas, small towns, and rural municipalities. By providing financial incentives, the programs aim to address the shortage of healthcare providers in these communities.

The Department is tasked with appointing a stakeholder work group by September 30, 2026, to streamline the application process for the loan repayment program. Overall, these measures are intended to enhance access to healthcare services in rural New York by encouraging professionals to practice in these underserved regions.

The document discusses a legislative change in New York that requires insurance companies governed by Article Thirty-Two of the Insurance Law to issue joint checks for payments related to out-of-network health care services. This new requirement aims to streamline the payment process between insured individuals and healthcare providers by ensuring that payments are directed appropriately.

Under this mandate, joint checks must be made out to both the insured and the healthcare provider. This approach is intended to enhance transparency and accountability in the payment process for out-of-network services.

The implementation of this law is expected to have financial implications for both insurance companies and healthcare providers, potentially altering cash flow dynamics and payment processing procedures within the industry.

The document outlines a comprehensive series of legislative amendments and provisions aimed at enhancing various sectors in the District of Columbia, with a strong focus on economic development, community support, education, public safety, and healthcare. Key initiatives include funding flexibility for Advisory Neighborhood Commissions, support for small businesses through delayed sales tax increases, and the establishment of programs like Baby Bonds to assist families financially. Significant allocations for public safety and education are highlighted, including funding for immigrant legal services and adjustments to public school funding formulas.

In the realm of community development, the document emphasizes the transfer of jurisdiction over the Rock Creek Tennis Center to the District government and the establishment of a program to preserve historic burial grounds for African Americans. Community land trusts will benefit from tax exemptions, and business licensing regulations are updated to encourage compliance. Additionally, funding for educational programs, particularly for special education and early childhood initiatives, is set to increase, ensuring better support for at-risk students.

Healthcare provisions include changes to the medical cannabis industry and expanded criminal background checks for child services providers. The document also addresses environmental health by transferring responsibilities related to lead poisoning prevention to the Department of Health. Furthermore, amendments aim to improve youth services through grant programs focused on employment and recidivism reduction, while reforming child support systems to better support families in need.

Public benefits are enhanced through the expansion of the Health Care Ombudsman Program, and new regulations for body art establishments are introduced to ensure safety. Significant financial allocations are made for stormwater management and energy initiatives, including the establishment of a Sustainable Energy Trust Fund. Additionally, new regulations are introduced to enhance road safety and update vehicle for hire regulations.

Overall, these legislative changes reflect a systematic approach to fund management and reallocation, aiming to enhance service delivery and support critical programs in healthcare, housing, education, and public safety. The amendments are designed to ensure that surplus revenues are effectively utilized to address community needs and promote sustainable development, ultimately fostering economic growth and improving public services in the District of Columbia.

The document discusses an act amending 1939 PA 280, aimed at improving medical services for eligible individuals in Michigan. The act is effective immediately as of December 23, 2025, and impacts various sectors within the healthcare industry.

Healthcare providers, including hospitals, physicians, and nursing homes, are directly affected as they are responsible for delivering the medical services specified in the act. Additionally, licensed pharmacists and pharmaceutical companies will be impacted due to the provisions related to pharmaceutical services, while facilities offering mental health care and substance use disorder treatment will also see changes.

Financially, the act mandates that the department reimburse hospital and nursing home services according to the state plan for medical assistance, pending approval from the United States Department of Health and Human Services. It outlines specific reimbursement rates for county-owned facilities, including a maintenance of effort rate that is limited to a $1.00 increase per patient day each year. Funding for pharmaceutical services and psychiatric care will depend on legislative appropriations for the fiscal year.

Furthermore, the act requires the director to inform the public about any proposed changes in the statewide reimbursement methods that could lead to payment fluctuations of 1% or more within a year. Overall, the act seeks to enhance the delivery of medical services while establishing clear guidelines for reimbursement and service provision within Michigan's healthcare system.

The document outlines amendments to health benefit requirements in Illinois for employees of counties, municipalities, and educational institutions, with a focus on post-mastectomy care and mental health and substance use disorder services. Health insurance providers are mandated to cover specific benefits related to these areas, ensuring compliance with federal parity laws.

Significant changes include the establishment of reimbursement rate floors for in-network mental health and substance use disorder services, which will impact the financial operations of health insurance providers and treatment facilities. These amendments aim to enhance health coverage for employees, particularly in mental health services, while imposing compliance requirements on local governments and schools.

Starting January 1, 2027, health insurance policies must cover all medically necessary mental health or substance use disorder services received on the same day from the same or different providers. Additionally, policies are required to cover 60-minute psychotherapy sessions billed under specific codes without imposing more stringent documentation requirements than for other psychotherapy services.

Insurers are also required to complete the contracting process with treatment providers within a specified timeframe, ensuring that providers are reimbursed at contracted rates for services rendered during the application process. The Department of Insurance will monitor the impact of these changes on network adequacy and access to care over the coming years.

Overall, these amendments are designed to significantly improve mental health and substance use treatment coverage in Illinois, establishing minimum reimbursement rates and expanding coverage requirements to better serve employees in the state.

AT A GLANCE

This bill requires the Department of Health to adopt rules within 180 days after the section’s effective date to implement rural emergency hospital licensure under defined federal and 24-hour emergency-stabilization requirements.

FULL SUMMARY

The bill establishes a state-level licensure framework for “rural emergency hospitals” (REHs) and defines REHs in multiple Hawaii statutes by tying eligibility to federal Medicare REH designation and requiring the hospital to provide emergency treatment and stabilization for an average length of stay of 24 hours or less, and to meet federal requirements in 42 U.S.C. § 1395x(kkk)(2). It directs the Department of Health to adopt implementing rules within 180 days after the section’s effective date, with a constraint that the rules cannot conflict with, be more restrictive than, or prevent federal REH regulations.

For Medicaid purposes, the bill expands existing Hawaii-law references to “critical access hospitals” (and related hospital-based units and sub-providers) so those references are interpreted to include “rural emergency hospitals,” but only when the REH was previously designated as a critical access hospital. It also adds a statutory definition of “rural emergency hospital” in the Hawaii provisions governing hospital payments and telehealth-related definitions, again linking the term to state-licensed REHs that were previously critical access hospitals.

The bill changes Medicaid payment methodology and protections in two ways. First, it revises the general payment-rate language to require that payments to critical access hospitals and rural emergency hospitals for services rendered to Medicaid beneficiaries be calculated on a cost basis using Medicare reasonable cost principles. Second, it amends Medicaid reimbursement equity language for long-term care by excluding critical access hospitals and rural emergency hospitals from a rule that otherwise bases reimbursement on level of care rather than location for institutionalized intermediate care facilities and institutionalized skilled nursing facilities.

Finally, the bill updates related statutory funding and re-enactment mechanics: it amends a 2000 session law to clarify the scope of appropriations used for the state’s share of matching funds to include rural emergency hospitals, and states that if funding is not available, Medicaid reimbursement for critical access and rural emergency hospitals reverts to the existing payment methodology. The act takes effect upon approval, except that the amendments made to §346-59.1 are not to be repealed when that section is reenacted on December 31, 2025 (per a specified 2023 law).

AT A GLANCE

This bill requires accident and health insurers and hospital or medical service plan contracts delivered in Hawaii after July 1, 2026 to cover participating registered pharmacists’ health maintenance or treatment services.

FULL SUMMARY

The bill establishes mandatory insurance coverage for health care services provided by participating registered pharmacists practicing within the scope of their licenses, contingent on the insurer/plan providing benefits for identical services when rendered by another health care provider. For accident and health or sickness insurance policies and for hospital or medical service plan contracts issued for delivery in Hawaii after July 1, 2026, coverage must include pharmacist-provided health maintenance or treatment services. It defines a “participating registered pharmacist” as a pharmacist licensed under Hawaii’s pharmacy licensing chapter who has contracted with the insurer (for insurers) or with the mutual benefit society (for mutual benefit societies) to provide health care services.

The bill also expands Medicaid reimbursement eligibility by amending (1) the definition of services eligible for prospective payment system reimbursement under section 346-53.64 to explicitly include services delivered exclusively by health care professionals, expressly listing pharmacists among those acting within the lawful scope of their licenses; and (2) the payment framework in section 346-59 to include pharmacists among the individual practitioner/provider types whose rate of payment is based on the Hawaii Medicaid fee schedule and constrained by federal and state limits. Separately, it expands the definition of “health care provider” for telehealth purposes in section 346-59.1 to expressly include pharmacists licensed under the pharmacy licensing chapter.

Finally, it directs the Department of Human Services to apply to the U.S. Department of Health and Human Services for any necessary Medicaid state plan amendments or Medicaid waiver(s) to implement the Medicaid-related changes in sections 4 through 6, with submission timing left blank in the text. The bill takes effect upon approval, except that sections 4 through 6 take effect upon approval of the Hawaii Medicaid state plan by CMS; it also preserves rights, duties, penalties, and proceedings that matured or began before the effective date.

AT A GLANCE

This bill requires Hawaii’s health authority to develop a universal “Hawaii care” single-payer plan, including eligibility and financing details, and report annually to the Legislature beginning with the 2026 regular session.

FULL SUMMARY

The bill establishes a universal, single payer health care system for Hawaii residents called “Hawaii care,” administered by a Hawaii health authority. It creates a new planning and implementation framework requiring the authority to develop a universal single payer plan, including eligibility, sequencing and financing, cost estimates for a benefits package covering mandatory benefits, recommended long-term/rehabilitation services, evaluations of health care and cost effectiveness, and hospital budgets. The authority must determine needed federal waivers, adopt implementing rules, and conduct specified research on provider burnout and current compensation practices; beginning with the 2026 regular session, it must report annually to the Legislature on implementation progress, the required business plan, research findings, and related recommendations.

The bill creates new statutory provisions establishing Hawaii care’s operational structure. It establishes a Hawaii care special fund in the state treasury, funded by legislative appropriations, gifts/grants, and federal funds, and limited to specified uses including administration, payments to third-party contractors, reimbursements to providers/facilities/hospitals for covered services to residents, and capital improvements (with an allowance for a community-based specialized services subaccount). It also establishes “Hawaii care” benefits at minimum coverage levels (hospital, surgical, broad medical including primary/preventive/acute/chronic care, diagnostics, prenatal/maternal/neonatal, substance abuse, mental health, emergency/ambulance, durable medical equipment, dental, vision, hearing, physical therapy, pharmacy/drug coverage, screening tests, and CDC-recommended vaccines) and requires an electronic insurance card as proof of coverage. Generally, required benefits are provided without cost sharing, while the bill also authorizes cost-sharing rules with a cap of $30 and allows supplemental health insurance as long as covered Hawaii care services are not billed to supplemental insurers.

The bill sets payment and delivery requirements aimed at simplifying financing and coverage. Hospitals must be funded through global budgets determined by the authority based on each hospital’s operational costs and not based on fee-for-service collections or capitation; unexpended/unencumbered funds by July 30 must roll into the next fiscal year budget. Independent providers and health care facilities must be paid on a fee-for-service basis using a standardized schedule negotiated annually and not based on capitation, with the authority required to provide enrollment and billing information to enable point-of-service enrollment. The bill also establishes a standalone Office of the Patient Advocate, independent of the authority, to investigate complaints regarding adverse decisions by the authority or participating entities. It requires network adequacy through a robust provider network and directs the authority to establish community-based program budgets for complex/specialized care needs (including mental health/substance abuse programs, home care, and collaborative support within primary care practices).

Implementation is supported through governance appointments, federal waiver processes, and funding/effective dates. The Governor must appoint Hawaii health authority members by December 31, 2025. The Department of Human Services must apply to amend the state Medicaid plan or obtain Medicaid waivers needed to implement Part III, and the State must submit an ACA section 1332 innovation waiver proposal to waive specified PPACA provisions, to be implemented upon federal approval. The bill appropriates $350,000 (or as needed) for general administration of the Hawaii health authority for fiscal years 2025–2026 and 2026–2027. The act takes effect July 1, 2025, but Part III takes effect 180 days after CMS approves the Hawaii Medicaid state plan.

The General Assembly of North Carolina has passed a bill to fund Medicaid rebase, which includes significant financial appropriations and intergovernmental transfers that will affect the healthcare sector. A total of $190 million in nonrecurring funds has been allocated from the Medicaid Contingency Reserve to the Department of Health and Human Services, Division of Health Benefits for the 2025-2026 fiscal year. This funding aims to adjust Medicaid financing based on anticipated changes in enrollment, service costs, and federal match rates.

Additionally, local management entities and managed care organizations (LME/MCOs) are mandated to make intergovernmental transfers amounting to $18,028,217 for the fiscal years 2025-2026 and 2026-2027. The contributions from each LME/MCO for the 2025-2026 fiscal year include $4,508,857 from Alliance Behavioral Healthcare, $3,544,348 from Partners Health Management, $6,448,693 from Trillium Health Resources, and $3,526,319 from Vaya Health.

The act is effective retroactively to July 1, 2025, with the appropriated funds and intergovernmental transfers applicable for the specified fiscal years. This legislation primarily impacts organizations involved in Medicaid services and management within the healthcare industry.

AT A GLANCE

This bill bars insurers and managed care plans from distinguishing participation, coverage, or payment for anesthesia services between licensed physicians and CRNAs, except when using identical quality measures.

FULL SUMMARY

The bill establishes requirements across multiple Massachusetts health coverage regimes to prevent differential reimbursement treatment between physicians licensed under chapter 112 and certified registered nurse anesthetists (CRNAs) authorized to practice in an advanced practice nursing role under section 80B of chapter 112, when the clinician is acting within the scope of practice under licensure and certification.

For coverage offered by the state’s commission (Chapter 32A), and similarly for Medicaid managed care/related arrangements handled by the Division (Chapter 118E), and for commercial accident and sickness and health insurance products (Chapters 175 and 176A), the bill bars distinctions in participation, coverage, and payment between physicians and CRNAs in covered anesthesia services, while allowing reimbursement differentiation only if based on quality/performance measures that are the same for both professions. It also requires claims to identify the National Provider Identifier (NPI) of the physician or CRNA who provided the service. In addition, the bill mandates that if a CRNA is a contracted provider, reimbursement to the CRNA must be not less than the allowed amount that would be reimbursed for the same service if furnished by a contracted physician; it further prohibits reducing reimbursement amounts paid to physicians to comply with these CRNA parity rules.

The bill extends similar parity requirements to medical service corporations and subscriber contracts under Chapter 176B (including by adding definitions for “Certified registered nurse anesthetist,” “medical service” including CRNAs, and “Participating certified registered nurse anesthetist,” and by striking “certified registered nurse anesthetist or” in section 4T wherever it appears). It adds comparable parity provisions to health maintenance organization contracting under Chapter 176G and to preferred provider arrangements under Chapter 176I. It also adds a rule that where a law or rule requires authorization or involvement of a physician as a condition for reimbursement or coverage of anesthesia services, that physician requirement may be satisfied by a CRNA practicing in an advanced practice role under section 80B.

Operatively, across these added sections the shared compliance themes are: (1) no provider-type distinction for participation/coverage/payment when acting within scope; (2) quality/performance-based variation is permitted only if measures are the same for physicians and CRNAs; (3) NPI identification is required on claims; and (4) contracted CRNA reimbursement must be at least the allowed amount for the same service when provided by a physician, with a prohibition on reducing physician reimbursement to implement the requirement.

AT A GLANCE

This bill requires hospital-associated providers to give advance written facility-fee notices and limits facility-fee charges when patients are scheduled, discharged, or moved to permissible locations.

FULL SUMMARY

The bill establishes a Massachusetts regulatory framework restricting “facility fees” and improving advance disclosure requirements for patients receiving hospital-associated services that may generate separate facility and professional charges. It adds new definitions and prohibitions in Chapter 111, creating requirements for where and when facility fees may be charged (generally limited to services provided on a hospital campus, at facilities with a licensed hospital emergency department, or for emergency services at licensed satellite emergency facilities), and it directs the Department of Public Health to implement regulations and penalties.

It also creates detailed patient-notice obligations when facility fees are charged: providers must give written notice that facility fees will be charged (and may be billed separately), with timing rules tied to the appointment date (at least 3 days after scheduling for appointments set at least 10 days out; otherwise on the premises, with explanations provided before discharge). Facilities must clearly identify the hospital association in signage/marketing/web presence, and must post prominent notices that patients may incur higher financial liability than if the service were received at a non-hospital facility. The bill further requires additional notice and limits billing (no facility fees for at least 30 days after notice) when a location changes status such that facility fees become permissible, and it makes violations an unfair trade practice under Chapter 93A in addition to monetary penalties.

In existing law, it revises the notice-and-billing rules for non-emergency services under Chapter 111 (Section 228(e)), striking the prior subsection and replacing it with new timing for informing patients about whether the provider participates in the patient’s health benefit plan (7 days advance for procedures scheduled more than 7 days out; 2 days advance for those scheduled less than 7 days out, with written notice upon patient arrival). The revised rule also maintains a limitation on billing the insured (except applicable copay/coinsurance/deductible) if required notifications are not provided or if unforeseen out-of-network services are rendered.

It amends Chapter 175H by adding definitions for “impermissible facility fee” and “surprise bill,” and replaces existing Sections 5 and 6 with (1) expanded attorney general investigation and civil-action authority and notification to relevant licensing authorities, (2) fraud/overpayment civil liability provisions that include claims related to impermissible facility fees, and (3) an additional prohibition on forwarding a “surprise bill” to covered insureds (with liability for penalties and attorneys’ fees and a corresponding civil-action right). It also adds a requirement in Chapter 176J that carriers reimburse specified services delivered by off-campus hospital outpatient departments and certain ambulatory settings at an equivalent of the Medicare non-facility physician rate, and it inserts a new Chapter 176O Section 30 establishing definitions, insured cost-sharing limits, and carrier reimbursement rules for “unforeseen out-of-network services,” including payment to out-of-network providers at the carrier’s median contracted rate (payment in full), exceptions for certain opportunities to choose network providers, an option framework for applying the rule to certain self-funded plans under ERISA, and a mandate that the commissioner promulgate implementing regulations.

The document introduces new provisions establishing an assessment on insurance providers, including Medicaid contracted health plans, health insurers, and specialty prepaid health plans. This assessment is structured into tiers with rates and conditions that depend on federal waiver approval, and it is based on member months reported in annual financial statements. The assessment rates may vary by tier and federal funding support, and the structure can be adjusted if the federal waiver is ended or modified.

The bill specifies procedures for notification, payment, and enforcement, including the suspension or revocation of licenses for nonpayment. It also clarifies that federal waiver approval is required for implementation and that the assessment structure is contingent upon federal authorization. Definitions necessary for understanding these provisions include "member months," "Tier 1, Tier 2, Tier 3 health plans," and "Federal funds authorized under subchapter XIX of the social security act." The provisions are effective starting October 7, 2025.

The document outlines significant legislative changes aimed at improving healthcare access for individuals experiencing homelessness in California. It highlights the severe health disparities faced by this population, with mortality rates significantly higher than those of housed individuals. The legislation emphasizes the integration of field medicine and shelter-based care, which have been shown to reduce hospital admissions and improve health outcomes for homeless individuals.

Key provisions include the requirement for Medi-Cal managed care plans to reimburse field medicine providers for services rendered to homeless beneficiaries. This initiative is expected to reduce hospital stays and associated costs, as individuals experiencing homelessness incur substantially higher healthcare expenses compared to their housed counterparts. The legislation also encourages collaboration between healthcare providers and social services to address the social determinants of health affecting this vulnerable population.

In addition to healthcare provisions, the document addresses the eligibility determination process for insurance affordability programs. It allows for self-attestation of various eligibility criteria, streamlines electronic verification of applicants' information, and establishes timeliness standards for eligibility determinations. The legislation aims to ensure continuous coverage for eligible applicants and facilitate a smooth referral process for those who may qualify based on age or disability.

Furthermore, the renewal procedures for insurance programs will accommodate multiple reporting methods, enhancing accessibility for applicants. Stakeholder engagement will be prioritized to gather feedback on eligibility systems, ensuring consumer advocacy and regular updates on system enhancements. Privacy and confidentiality rights will be upheld in accordance with federal regulations.

Overall, the legislation seeks to address critical barriers to healthcare access for homeless individuals, aiming to improve health outcomes and reduce costs within the healthcare system while enhancing the efficiency of eligibility determination processes for insurance affordability programs.

AT A GLANCE

This bill requires eligible local educational agencies to maintain MassHealth reimbursement proceeds for school-based services and related administrative activities at their operated schools and bars using the proceeds to supplant existing funding.

FULL SUMMARY

The bill changes Massachusetts law to ensure MassHealth school reimbursement proceeds are handled by “local educational authorities” (instead of “local government entities”) and to require that MassHealth-funded school-based services and related administrative activities are retained for school health purposes rather than treated as unrestricted local revenue.

In chapter 44, section 72, the bill replaces the term “local government entity” with “local educational authority” in three places and replaces existing language on how funds received under the section may be classified and spent. Under the new language, a local educational agency that obtains MassHealth reimbursement for school-based services, administrative activities, or other medical benefits must maintain the proceeds to fund school-based services and related administrative activities at the facilities or school systems it operates or over which it has direct supervision or jurisdiction, and the proceeds may not supplant existing or planned school health funding.

The bill also adds a new section 99 to chapter 71 defining key terms for school-based Medicaid reimbursement. Definitions include “administrative activities” (as in the local educational agency’s MassHealth provider contract), “local educational agency” (cities, towns, charter schools, public health commissions, and school districts), “school-age child” (ages 3 through 22 without a high school diploma or equivalent), “school-based Medicaid provider” (a local educational agency providing School Based Services and administrative activities under its MassHealth provider contract), “school-based services” (medically necessary MassHealth covered services under the Medicaid State Plan), and “school personnel” (named categories of salaried/contract staff such as nurses, therapists, special education administrators, psychologists, social workers, counselors, and clerical support). The executive office of health and human services and the executive office of education must ensure each eligible local educational agency implements a plan to obtain MassHealth reimbursement for school-based services, administrative activities, and other medical benefits for eligible MassHealth beneficiaries, consistent with state Medicaid law.

The new section further provides that, notwithstanding other law or regulation, enrolled local educational agencies may submit claims to MassHealth for reimbursement for providing these services and medical benefits through their employees or agents. Reimbursement is required regardless of whether the school-age child participates in an individualized education program, an individual health care plan, or a plan under Section 504 of the Rehabilitation Act, and regardless of whether services are provided at no charge to non-eligible children. Finally, it directs that reimbursement proceeds be used for school-based services and related administrative activities and may include, without limitation, enhanced behavioral health capacity, case management, health education and social-emotional learning, outreach and enrollment, school health infrastructure development, and other related school health services.

The General Assembly of North Carolina has enacted significant changes to Medicaid funding and state agency operations, which will have substantial financial implications across various sectors. Key measures include the elimination of vacant positions in state agencies, with a target reduction of at least $19,742,243 in recurring funds by October 1, 2025. The Department of Health and Human Services (DHHS) is also mandated to achieve net General Fund savings of $32,613,493 through similar reductions. Additionally, Medicaid funding will be adjusted with an appropriation of $690 million for the 2025-2027 fiscal biennium, alongside specific allocations for managed care operations.

Changes to Medicaid eligibility processing have been introduced, requiring county departments of social services to make decisions on applications within set timeframes. The Department will enforce standards for processing times and initiate corrective actions if counties fail to meet these standards. A corrective action plan will be established for counties that do not comply, with the potential for the Department to temporarily assume Medicaid eligibility administration if necessary.

The document also outlines provisions for the administration of Medicaid and the Supplemental Nutrition Assistance Program (SNAP), emphasizing the importance of accuracy and quality assurance in eligibility determinations. The DHHS will oversee funding and compliance at the county level, with annual reporting requirements to monitor performance metrics. Performance audits will be conducted to ensure adherence to standards, with specific funding allocated for these audits.

Financial provisions affecting the state budget for the fiscal years 2025-2026 and 2026-2027 include a reduction in transfers from the General Fund to the State Capital and Infrastructure Fund and the management of unexpended bond proceeds for various capital improvement projects. These changes are expected to impact the healthcare and social services sectors, as well as businesses involved in state-funded infrastructure projects, due to adjustments in funding allocations and project financing.

The District of Columbia has enacted a comprehensive budget for the fiscal year ending September 30, 2026, totaling approximately $22 billion. This budget allocates funds from local sources, dedicated taxes, and federal grants to support essential governmental functions and services, with significant investments in public safety, education, economic development, and health services. Notably, over $1.9 billion is designated for public safety initiatives, including funding for the Metropolitan Police Department and Fire and Emergency Medical Services, while approximately $4.3 billion is allocated to public education systems.

Economic development efforts receive around $549 million, aimed at fostering growth and supporting small businesses. Health and human services are prioritized with nearly $8 billion allocated to various departments, ensuring continued support for vulnerable populations. The budget emphasizes the importance of ongoing funding for critical services, with many appropriations authorized for expenditure until September 30, 2026.

Additionally, the budget includes a significant net increase of $1.7 billion for capital construction projects, sourced from local, federal, and transportation funds. An increase of up to $51.5 million in local funds is also authorized for various programs, including childcare subsidies and housing initiatives. Specific allocations address public safety and housing needs, such as lead-pipe testing in charter schools and housing incentives for police officers.

Overall, the budget reflects a strategic financial plan aimed at enhancing the quality of life for residents through targeted investments across multiple sectors, including education, healthcare, and public safety. The comprehensive approach underscores a commitment to improving services and infrastructure in the District of Columbia.

AT A GLANCE

This bill prohibits third-party payers from reducing reimbursement for covered health care services based on the payer’s own code-description comparisons or on bundled additional services billed on the same date.

FULL SUMMARY

The bill establishes restrictions on when a third-party payer may reduce reimbursement to health care providers.

It changes Ohio Revised Code section 3901.385 by modifying the prohibition on reimbursement reductions: a third-party payer may not reduce reimbursement for a covered health care service based on the payer’s own description of what is included in that service as compared to (i) the most current CPT code, (ii) the most current ICD-10 code, (iii) the most current CDT code, or (iv) the most current HCPCS code (as published by the specified external code-setting authorities). It also prohibits reimbursement reductions based on the payer’s own description of what is included in the diagnosis code submitted on the claim when that description is outside guidelines established by entities responsible for the code set, including CDC’s National Center for Health Statistics.

Additionally, the bill prohibits reimbursement reductions on the ground that the provider billed additional health services (including outpatient surgery) on the same date as the covered service.

The bill also repeals the existing version of section 3901.385 and replaces it with the modified text above (effective upon enactment, with no other specific effective date stated in the text provided).

AT A GLANCE

This bill prohibits health plan issuers from requiring or inducing providers to collect covered persons’ cost-sharing and requires issuers to reimburse providers directly for covered services beginning January 1, 2027.

FULL SUMMARY

The bill would establish a new Ohio statutory section (R.C. 3902.55) governing how health plan issuers and providers handle patient cost-sharing.

It creates definitions for “benefits contract,” “health care service,” “provider,” and “reimburse,” and then imposes requirements beginning January 1, 2027 that: (1) no health plan issuer may require or induce providers to collect patient cost-sharing amounts (including copayments and deductibles) from covered persons; and (2) issuers must make all reimbursement for covered services directly to the health care provider.

It limits how existing benefits contracts/health benefit plans are treated by providing that the new direct-payment and anti-inducement rules do not apply to the extent they conflict with contracts or plans entered into before January 1, 2027, unless those contracts or plans are amended or renewed after that date. For plans/contracts entered into, amended, or renewed on or after January 1, 2027, it also prohibits such arrangements from requiring providers to collect cost sharing from covered persons or requiring covered persons to pay cost sharing amounts to a provider.

The bill clarifies that it does not prohibit providers from collecting amounts owed for uncovered services and does not prohibit providers from accepting a cash payment from a covered person in lieu of accepting reimbursement under a health benefit plan.

The document outlines significant amendments to California's health care regulations, focusing on enhancing access to services and improving public health. Notably, health care practitioners and emergency medical services personnel from other states will be exempt from California licensure requirements while providing services during the 2028 Olympic and Paralympic Games. The State Department of Public Health will also have the authority to modify immunization recommendations based on federal guidelines, and a standardized electronic medical exemption certification form for schools will be established.

Key provisions include the establishment of an Abortion Access Fund to support abortion services and mandates for the California Health Benefit Exchange to cover state-mandated gender-affirming care benefits. Additionally, the document addresses immunization liability protections for individuals and organizations administering vaccines, ensuring they are not held liable for injuries if they comply with applicable standards. Coverage for COVID-19 testing without cost-sharing in disability insurance policies is also mandated.

Changes to Medi-Cal benefits are highlighted, particularly for non-citizens, who will have limited access to services based on their immigration status. The amendments introduce monthly premiums for certain individuals while ensuring others retain full benefits until specific age thresholds. The document emphasizes the importance of preventive care, including comprehensive benefits for children and funding for breast cancer research and control programs.

Furthermore, the amendments aim to improve healthcare access for vulnerable populations through an appeals process for affected individuals and a pilot program to identify veterans and their dependents enrolled in Medi-Cal. Coverage for vaccines and immunizations will be mandated based on recommendations from recognized health organizations, and funding will be allocated for medical interpretation services for Limited English Proficient Medi-Cal beneficiaries.

Overall, these amendments reflect a commitment to addressing the healthcare challenges faced by various populations in California, ensuring compliance with evolving healthcare needs, and enhancing access to essential services.

AT A GLANCE

This bill prohibits participating and nonparticipating ground ambulance providers from billing covered persons more than the covered cost-sharing amount for covered ground ambulance benefits.

FULL SUMMARY

The bill creates new statutory provisions governing reimbursement for ground ambulance services under New Hampshire’s managed care law, establishes a commission to study and improve the ground ambulance financing and delivery system, and prohibits “surprise” or balance billing for covered persons receiving ground ambulance services.

It adds a new RSA 420-J subdivision establishing (1) definitions for ground ambulance providers and services, including “enrolling,” “participating,” and “nonparticipating” providers; (2) a mandatory rate schedule for reimbursement by health carriers, with a temporary rate of 3.25 times the applicable Medicare rate for participating/enrolling providers for 2026–2027; and (3) a transition to a statewide, cost-based rate schedule adopted by the commissioner effective January 1, 2028 and annual inflation adjustments thereafter. The bill also requires nonparticipating providers to be reimbursed at the carrier’s nonparticipating rate or the current Medicare rate (whichever is higher). It requires the commissioner to publish standardized contract template language by December 31, 2025, requires carriers to offer the standardized contract to qualified providers, and sets rules on maintaining “enrolling” status through good-faith contracting engagement.

The bill repeals several existing RSA 420-J provisions relating to the prior definition of enrolling providers, temporary 2026–2027 reimbursement rates, and contracting/registry rules (RSA 420-J:21(I)(a), RSA 420-J:24, and RSA 420-J:25), and it replaces the removed content with the new managed-care framework described above. It also creates an independent accounting and actuarial cost study of ground ambulance costs, requires data collection, validation, and auditing by an expert, allows loss of access to the temporary participating/enrolling rate schedule for non-cooperating providers, and directs an expert report and recommended cost-based reimbursement schedule by June 30, 2027, including assessment of feasibility for a federal Section 1115A all-payer model for ground ambulance services.

To address patient billing, the bill adds RSA 358-T:1 definitions for ground ambulance provider/services and adds RSA 358-T:5, prohibiting participating or nonparticipating ground ambulance providers from billing covered persons for amounts exceeding the covered person’s cost-sharing requirement when the covered benefits include ground ambulance services; it includes an exception for certain scheduled inter-facility transfers by nonparticipating providers only if the provider meets federal notice and consent criteria under 42 U.S.C. § 300gg-132(c) and (d). The bill additionally establishes RSA 153-A:38, creating a commission with specified legislative and stakeholder membership, charging it with reviewing the ground ambulance delivery/financing system, evaluating policy reform options, assessing a potential Section 1115A waiver/all-payer design, and issuing annual progress reports on November 1 (with the waiver feasibility/advisability assessment due in the November 1, 2027 report). Finally, it creates funding mechanics for the independent study by directing up to $400,000 in certain insurance enforcement fines (for state fiscal years ending June 30, 2026 and June 30, 2027) to the insurance department administration fund for contracting the study; any amounts above that cap go to the general fund, and any unused portion is transferred to the general fund.

Effective dates: the replacement reimbursement changes for nonamended parts take effect January 1, 2026 (for the billing/provider definition provisions) and January 1, 2028 (for the updated participation cost-based reimbursement rate schedule), the commission takes effect June 30, 2030, and the specified fines-deposit provision takes effect July 1, 2027; the remaining provisions take effect upon passage.

AT A GLANCE

This bill requires the commissioner of the Department of Health and Human Services to provide Medicaid payments to hospitals starting in state fiscal year 2026 based on prior-year RSA 84-A collections, subject to CMS approval and related waivers.

FULL SUMMARY

It establishes a new funding and payment framework for the state’s uncompensated care and Medicaid-related hospital payments through the “Uncompensated Care and Medicaid Fund,” and revises related statutory definitions and references. Beginning in state fiscal year 2026, the commissioner of the Department of Health and Human Services must provide Medicaid payments (state and federal fund equivalent) to hospitals in amounts tied to collections under RSA 84-A in the prior state fiscal year, using CMS-allowable payment methods (including reimbursement, supplemental payments, managed care directed payments, disproportionate share hospital adjustments, and other CMS-approved methods). All such payments require CMS approval and any necessary state plan amendment approvals and waivers; directed payments must comply with federal directed payment rules.

The bill clarifies how disproportionate share hospital (DSH) payments may be made, limiting eligibility to hospitals that are either “deemed disproportionate share hospitals” under federal criteria (and not already receiving DSH) or meet minimum DSH eligibility under relevant federal changes. It specifies that, for DSH calculation purposes, uncompensated care costs used by the commissioner include charity care costs and unreimbursed Medicaid-covered patient care costs that meet federal hospital-specific limits. It also conditions payment on receipt of the federal share and necessary CMS approvals, states the state is not liable for amounts beyond available federal appropriated funds, and provides that if CMS does not approve a directed payment plan, the commissioner must pursue alternative CMS-allowable methods (e.g., increased rates, DSH, supplemental payments) that preserve federal matching; the state is not liable for directed-payment amounts hospitals fail to earn.

The measure restructures the funds: it creates and separately maintains an “uncompensated care and Medicaid fund” in the state treasury (nonlapsing and continually appropriated for hospital/provider and Medicaid support purposes) and creates a separate “disproportionate share hospital fund” within the Department of Health and Human Services to receive all disproportionate share hospital revenue for redistribution to comply with federally required DSH examinations. It requires that (i) at least 9% of RSA 84-A collections from the prior state fiscal year support Medicaid services/programs with first priority for specified provider categories (community mental health centers, federally qualified health centers, substance use disorder providers, and other Medicaid providers as determined by the commissioner), and (ii) 1% of the hospital Medicaid payment funds be placed in a separate class line for administering the section. It requires an informational submission to the fiscal committee before implementing any change in Medicaid payment methodology under specified subsections.

Finally, it establishes a bipartisan legislative committee to study the Medicaid enhancement tax and New Hampshire disproportionate share hospital payments, including their relationship and the feasibility of moving to a directed payment plan. The committee must solicit testimony, draft potential legislation for issues identified, and report findings and recommendations on or before November 1, 2025. Key related changes include revising the RSA 167:63 hospital definition to exclude government and special rehabilitation hospitals, updating RSA 167:64 to create/define the new fund and payment mechanics, adjusting an RSA 6:12 reference to the revised disproportionate share hospital fund section, and the act takes effect July 1, 2025 (per the effective date section on page 5).

The document outlines significant amendments to health care regulations in California, focusing on enhancing access and equity for marginalized communities, particularly transgender, gender nonconforming, and intersex individuals. Key changes include the establishment of the Transgender, Gender Nonconforming, and Intersex (TGI) Wellness and Equity Fund, which will provide ongoing financial support for health care programs, and an increase in financial eligibility standards for accessing medications to 600% of the federal poverty level by 2025. Additionally, large group disability insurance policies will be required to cover infertility diagnosis and treatment without discrimination based on gender identity or sexual orientation.

Modifications to the Medi-Cal program include changes to eligibility determinations, with new resource disregards and the removal of prior authorization for hospice services by 2027. The amendments aim to streamline access to health care services for vulnerable populations, including those with disabilities and low-income individuals. New benefits will be introduced, such as nonmedical transportation and rapid whole genome sequencing for young children, expanding the range of services available to Medi-Cal beneficiaries.

The document also addresses reimbursement policies for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), allowing for adjustments to reimbursement rates based on changes in the scope of services provided. Telehealth services will be expanded, requiring these centers to offer both video and audio-only interactions, thereby enhancing access to healthcare services. Furthermore, changes to Medi-Cal managed care enrollment requirements will streamline processes and ensure that non-dual-eligible beneficiaries receive necessary healthcare services.

In addition, the document emphasizes the need for improved access to behavioral health services, particularly for children and youth, and imposes new responsibilities on local agencies regarding Medi-Cal eligibility. Enhanced patient privacy protections and timely reporting of breaches related to medical information are also highlighted, alongside the requirement for pharmacy benefit managers to obtain licenses and provide data on drug pricing starting in 2027.

Overall, these amendments aim to improve health care access, enhance patient care standards, and ensure compliance within the health care system, with a focus on promoting equity and improving access to essential health care services for all Californians.

The document outlines legislative changes in Hawaii aimed at addressing the physician shortage by expanding the role of registered pharmacists in healthcare. Starting January 1, 2026, private health plans will be required to reimburse services provided by registered pharmacists practicing within their scope of practice, ensuring that coverage cannot be denied for these services.

The legislation impacts various health insurance providers, including private and public health plans, mutual benefit societies, and health maintenance organizations (HMOs). It clarifies that participation in a policy with prescription drug benefits does not exempt health plans from including registered pharmacists in their network of participating providers.

Additionally, registered pharmacists will be allowed to contract with health plans if they meet standard credentialing requirements, with certain exemptions. Credentialing delegated to healthcare facilities will also be accepted for pharmacists employed by those facilities. Public health plans will similarly be required to reimburse pharmacist services, pending approval from the Centers for Medicare and Medicaid Services.

These changes aim to enhance patient care by effectively utilizing pharmacists in the healthcare system, potentially leading to improved health outcomes and reduced hospital readmissions. The overall Act is set to take effect on December 31, 2050.

The document outlines significant amendments to California's health laws, focusing on enhancing healthcare access, equity, and quality for various populations, including marginalized groups such as transgender, gender nonconforming, and intersex individuals, as well as low-income and disabled persons. Key changes include the establishment of the TGI Wellness and Equity Fund to support organizations serving TGI communities, and the requirement for large group disability insurance policies to cover infertility diagnosis and treatment, ensuring equitable access regardless of gender identity or sexual orientation.

Modifications to the Medi-Cal program aim to expand benefits and services for recipients, including the introduction of nonmedical transportation, coverage for rapid whole genome sequencing for infants, and the provision of home test kits for STDs. Additionally, violence prevention services and community health worker services will be covered, enhancing access to healthcare for vulnerable populations. Changes to reimbursement policies for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) will also improve financial operations and service delivery models.

The amendments further address the regulation of pharmacy benefit managers, requiring them to register and comply with new operational standards, including financial reporting and the establishment of a Pharmacy Benefit Manager Fund. Skilled nursing facilities will be mandated to ensure preparedness for power outages, reflecting a focus on operational resilience within the healthcare system.

Changes to Medi-Cal eligibility criteria include the removal of resource considerations for non-MAGI cases and the introduction of a disregard for certain nonexempt property. The bill also mandates that Medi-Cal managed care plans cover COVID-19-related services without cost-sharing and eliminates prior authorization requirements for hospice services. These adjustments aim to streamline eligibility determinations and enhance the efficiency of the Medi-Cal program.

Overall, these amendments reflect a comprehensive effort to improve healthcare access, promote equity, and ensure that vulnerable populations receive necessary support and services in California. The changes are expected to impact healthcare providers, community organizations, and insurance companies, necessitating adjustments in operations and service delivery to align with the new regulations.

This legislative act amends the Insurance Code of Texas to modify health benefit plan preauthorization requirements for certain healthcare services. A significant change is that utilization review agents must conduct reviews under the supervision of a licensed physician, who cannot be licensed in administrative medicine. This adjustment affects health maintenance organizations (HMOs) and insurers involved in utilization reviews.

The act introduces exemptions from preauthorization for specific healthcare services if, during the most recent evaluation period, at least 90% of requests from a physician or provider for that service were approved, provided the service was rendered at least five times. This aims to streamline the preauthorization process and alleviate administrative burdens on healthcare providers.

Annual evaluations are now mandated to determine if a physician or provider qualifies for an exemption from preauthorization requirements, a change from the previous six-month evaluation period. Additionally, exemptions can only be rescinded in January of each year after a retrospective review of claims, with specific provisions for cases with fewer than five claims submitted.

Physicians and providers are granted the right to an independent review of adverse determinations regarding preauthorization exemptions without needing to engage in an internal appeal process first. Furthermore, HMOs and insurers are required to submit annual reports detailing exemptions granted, rescinded, or denied, along with the outcomes of independent reviews, which will be made public with identifying details removed.

These amendments primarily impact the healthcare industry, particularly providers and insurers, by altering the processes surrounding preauthorization and utilization reviews, potentially leading to reduced administrative costs and improved access to necessary healthcare services.

This legislation establishes provisions for direct payment to hospitals for health care services provided to patients who are not enrolled in a health benefit plan. It mandates that hospitals must accept full payment directly from patients upon request within a specified timeframe after billing.

Hospitals are permitted to charge patients amounts that do not exceed a certain percentage above their generally billed amounts or the lowest contracted rates with other health benefit plans, excluding specific programs like Medicaid and Medicare.

The act is set to take effect on September 1, 2025, and is expected to impact the health care industry, particularly hospitals, by changing payment structures and potentially affecting revenue from uninsured patients.

Additionally, it emphasizes the importance of transparency in billing practices and reinforces patient rights regarding payment options.

This legislative act amends the Texas Insurance Code to establish new eligibility criteria for mediation of out-of-network health benefit claims. It permits out-of-network providers and health benefit plan issuers or administrators to request mandatory mediation within 180 days following the initial payment for health care services or supplies.

The amendments specifically address disputes related to services rendered on or after the act's effective date. For disputes concerning services provided prior to this date, the previous law will apply if mediation is requested within 120 days after the act takes effect. If mediation is not sought within this specified timeframe, the dispute will be ineligible for mediation.

The act is designed to impact various business sectors, including health care providers, insurance companies, and health benefit plan administrators. While specific financial implications are not detailed, the changes are expected to affect the financial dynamics between out-of-network providers and health benefit plans.

This legislative act amends the Government Code in Texas, specifically altering the reporting requirements for the Health and Human Services Commission (HHSC). The data analysis unit is now mandated to provide annual reports by December 1 each year, shifting from quarterly updates. Additionally, the commission is required to prepare biennial reports on specific interventions and best practices, changing the frequency from semiannual to every even-numbered year.

The commission will also conduct assessments of Medicaid service implementations, including acute care and long-term services for individuals with intellectual or developmental disabilities. These assessments will include recommendations for improvements and necessary statutory changes. Furthermore, a comprehensive evaluation of a pilot program focusing on access, quality of services, and participant experiences is due by September 1, 2026, and will be included in the biennial report.

Reports submitted to the legislature must include aggregate, non-identifying data related to quality-based outcome measures. All reports required by the Health and Safety Code are to be submitted by December 1 of the year they are due. If any provision requires a federal waiver or authorization, its implementation may be postponed until such waiver is granted.

The act will take effect immediately if it receives a two-thirds vote from both houses; otherwise, it will become effective on September 1, 2025. The changes will impact healthcare providers, particularly those involved in Medicaid services, as well as organizations offering long-term care and support services, potentially increasing their administrative responsibilities and financial implications due to the new reporting requirements and assessments.

This legislation amends the Texas Insurance Code to improve the involvement of optometrists and therapeutic optometrists in vision care plans. It mandates that vision care plan issuers provide a standardized application process for these professionals to become participating providers, ensuring that all applicants are evaluated under the same criteria.

Issuers are required to respond to applications within specific timeframes, including providing contracts for compliant applications within 10 business days and completing credentialing determinations within 30 business days. Additionally, approved applicants must be included as participating providers within 20 business days after accepting the contract.

The legislation also prohibits issuers from excluding optometrists or therapeutic optometrists based on the number of providers in a geographic area or concerns about patient access. Furthermore, contracts between managed care plans and optometrists must include electronic access to fee schedules and utilize standardized codes for covered services.

To protect optometrists and therapeutic optometrists, the use of extrapolation in audits is prohibited, ensuring that any financial adjustments are based on actual claims rather than estimates. The changes will apply to contracts entered into or renewed after the effective date of the Act, which will take effect immediately if it receives a two-thirds vote from both houses or on September 1, 2025, otherwise.

The impacted industries include vision care providers, managed care organizations, and insurance companies involved in vision care plans, although specific monetary impacts are not detailed.

The document outlines significant amendments to the Illinois Administrative Procedure Act and the Illinois Public Aid Code, focusing on Medicaid reimbursement rates and assessments imposed on hospital providers. These changes primarily affect hospital funding structures, with specific assessment rates established for inpatient and outpatient services across various fiscal years. The assessments for inpatient services will vary, with rates set at $218.38 per occupied bed day for fiscal years 2009 through 2018, decreasing to $197.19 for 2019 and 2020, and increasing to $221.50 for the period from July 1, 2020, through December 31, 2026, before rising to $362 starting January 1, 2025.

Outpatient services will also face annual assessments based on a percentage of the hospital's gross revenue, with rates increasing over time to ensure adequate funding for Medicaid payments. Special provisions are included for safety-net hospitals that have undergone ownership changes and experienced significant decreases in utilization, allowing them to pay assessments based on hypothetical data until the end of 2023. The document emphasizes the need for timely implementation of these changes to address the financial needs of hospital providers in Illinois.

Additionally, the document establishes a Hospital Provider Fund to manage the disbursement of funds for various healthcare-related purposes, including payments to hospitals and administrative expenses. It outlines specific monetary transfers to support critical access hospitals and safety-net hospitals, as well as funding aimed at addressing infant mortality and improving rural healthcare access. The changes are designed to enhance the financial stability of hospitals while ensuring compliance with federal regulations and improving healthcare access for vulnerable populations.

The Illinois Public Aid Code is being amended to enhance the role of doulas in hospitals and birthing centers. Under the new provisions, all hospitals with licensed obstetric beds and birthing centers must adopt written policies that permit patients enrolled in the medical assistance program to have a certified and enrolled doula of their choice accompany them during labor and childbirth.

This amendment primarily affects the healthcare industry, particularly hospitals and birthing centers, as well as the doula profession and related organizations. While specific monetary impacts are not detailed, the requirement for hospitals to implement new policies may lead to administrative costs. Additionally, the inclusion of doulas in the birthing process could influence healthcare costs associated with maternal and reproductive health services.

The amendment also clarifies that doulas will not count against the facility's guest quota and outlines the responsibilities and liabilities of hospitals and doulas regarding the care provided.

The document outlines significant amendments to New York's public health and insurance laws, focusing on standards for utilization review programs and the pre-authorization of health care services. A key change mandates that clinical review criteria used in utilization reviews must be evidence-based and peer-reviewed, ensuring they reflect the needs of typical patient populations and diagnoses.

Utilization review agents are now required to notify enrollees and their health care providers of determinations regarding pre-authorization within 72 hours of receiving the necessary information. For inpatient rehabilitation services, this notification must occur within one business day, enhancing the timeliness of communication.

The amendments also emphasize financial transparency by requiring notifications to clarify whether services are in-network or out-of-network, detailing the enrollee's financial responsibilities and anticipated out-of-pocket costs for out-of-network services. This change is expected to impact health care providers, insurance companies, and patients by potentially altering payment structures.

Additionally, approvals for pre-authorization requests will now be valid for the duration of the prescription, including authorized refills, and for the entire treatment period for a specific condition as requested by the health care provider.

These changes primarily affect the health care and insurance industries, highlighting the need for compliance with new standards and potentially altering operational processes related to pre-authorization and utilization reviews.

The recent legislation introduces significant amendments to the regulation of vision insurance and vision care in Nevada, aiming to enhance consumer protection and ensure fair practices within the industry. Key provisions include prohibitions on certain practices by vision insurance providers, such as conditioning participation of vision care providers based on their involvement in other plans and controlling their professional judgment. Additionally, vision care providers are required to disclose any ownership interests in suppliers of ophthalmic devices, promoting transparency in the industry.

The amendments also extend to various sections of the Nevada Revised Statutes, impacting not only vision insurance but also other insurance-related entities, including health maintenance organizations and prepaid limited health service organizations. These changes emphasize the importance of accurate advertising and prohibit misleading practices, ensuring that enrollees receive clear and truthful information about their coverage options.

Furthermore, the legislation addresses the administration of group life, accident, or health insurance for governmental employees, allowing for self-insurance reserve funds and establishing guidelines for contract approvals with legal services organizations. This aims to streamline insurance provision for local governmental agencies, including school districts and municipalities.

Overall, the amendments reflect a comprehensive effort to enhance regulatory oversight, protect consumer rights, and promote transparency across the insurance landscape in Nevada. By implementing these changes, the legislation seeks to prevent unfair trade practices and improve the overall integrity of the vision insurance and broader insurance markets.

The proposed amendments to health insurance regulations in Nevada introduce significant changes aimed at improving the efficiency of claims processing and enhancing consumer rights. Health insurance carriers and administrators are now required to approve or deny claims within specific timeframes: 21 days for electronically submitted claims and 30 days for non-electronic submissions. If additional information is needed, carriers must request it within 20 working days and make a decision within the same timeframe after receiving the information.

Insurers must provide written notifications to claimants regarding claim denials, including the reasons for denial and the criteria used for decision-making. Additionally, if an approved claim is not paid within the specified periods, insurers are obligated to pay interest at a rate of 10 percent per annum, calculated from the due date until the claim is settled. Annual compliance reports detailing adherence to these requirements must be submitted to the Commissioner by February 1 each year.

The amendments also emphasize consumer rights, allowing insured individuals to file complaints, appeal adverse determinations, and request expedited external reviews if their health is at risk. These changes are designed to create a more accountable and efficient health insurance environment, particularly benefiting small healthcare practices and minority communities.

Certain programs, including Medicaid and the Children’s Health Insurance Program, are exempt from these new requirements. The overall goal of the legislation is to enhance the healthcare infrastructure in Nevada, ensuring timely payments and improved access to healthcare services for residents.

The 69th Legislature of Montana has introduced a bill to establish a standardized cost reporting process for certain Medicaid service providers, aimed at improving the understanding of Medicaid rate adequacy. This initiative will require specific service providers, including those in adult and children's mental health services, substance use disorder treatment, developmental disabilities services, and senior care, to report their actual costs and revenues. The Department of Public Health and Human Services (DPHHS) will implement this reporting format, collecting data at least once every four years, with the first report due by September 1, 2026.

Additionally, the document outlines the administration of home and community-based services programs funded through various sources, including state and federal funds. The department is responsible for ensuring that expenditures remain within available funding and may implement financial participation requirements for enrollees. Target populations for these services include individuals with developmental disabilities, chronic mental illness, and those aged 65 and older. The department may limit enrollment and expenditures if costs are projected to exceed funding.

Furthermore, provisions related to home and community-based services under Medicaid emphasize eligibility criteria, provider requirements, and reimbursement rates. Children in foster care must have access to these services if eligible, and reimbursement rates for pediatric complex care assistants should reflect the specialized skills required. The department is also tasked with creating rules for transitioning individuals from waiting lists into waiver services and ensuring fraud prevention training and cost reporting.

Monetary impacts associated with these changes include appropriations of $600,000 from the general fund and $600,000 in federal special revenue for the development of mandated reports, effective July 1, 2025. Overall, these initiatives aim to enhance the financial operations and reimbursement structures within the affected service sectors, ensuring that Medicaid service provider rates are aligned with actual costs incurred.

The document outlines significant amendments to Medicaid coverage in Nevada, specifically aimed at individuals under 21 years of age who are ineligible due to immigration status. Effective from April 18, 2025, these changes will provide coverage for emergency medical transportation, emergency room care, inpatient services, and limited treatment for certain conditions such as renal disease and cancer, contingent upon prior approval from the Department of Health and Human Services.

Healthcare providers, including hospitals, emergency medical services, and clinics, will be directly affected by the new coverage requirements and reimbursement rates. Additionally, pharmaceutical companies may need to adjust their practices regarding the provision of prescription drugs under the updated conditions. The fiscal implications for the state budget are noted, particularly concerning the Department's efforts to secure increased reimbursement rates for services related to pediatric cancer and rare childhood diseases.

The document emphasizes the importance of determining medically necessary care to prevent conditions from escalating into emergencies. The Department of Health and Human Services is tasked with establishing procedures for this determination and managing the administrative responsibilities associated with the new provisions.

By January 1, 2026, the Director of the Department must identify services commonly provided for pediatric cancer and rare childhood diseases and submit a request to amend the State Plan for Medicaid to increase reimbursement rates by at least 2%. This initiative aims to enhance support for vulnerable populations while ensuring effective administration of the expanded Medicaid coverage.

The document outlines significant provisions related to reproductive health services and Medicaid coverage, emphasizing the impact on healthcare providers and related industries. The legislation primarily affects those offering reproductive health services, including pharmacies dispensing contraceptives and providers involved in education and counseling on contraceptive use. Additionally, translation service providers may be impacted due to new requirements for language translation in the provision of covered contraceptive drugs and devices.

Monetary implications of the bill include appropriations from the State General Fund for the fiscal years 2023-2024 and 2024-2025, aimed at covering costs associated with Medicaid translation services and administrative changes. The Division of Health Care Financing and Policy is also authorized to utilize non-General Fund sources for these purposes, indicating a structured approach to funding the necessary services.

The provisions of the act will apply to all state and local laws enacted before, on, or after January 1, 2024. Specific sections related to translation services will take effect on July 1, 2023, while the broader provisions will commence on January 1, 2024, following necessary administrative preparations.

Overall, the legislation seeks to enhance access to reproductive health services, ensuring that Medicaid beneficiaries are not burdened with additional costs for contraceptive drugs and devices, while also addressing the need for translation services in healthcare settings.

The document outlines changes to Medicaid reimbursement policies for providers of nonemergency secure behavioral health transport services in Nevada. These changes primarily impact transportation companies that specialize in mental health services.

The new policy mandates an increase in reimbursement rates for these services, with a minimum increase of 15% for providers in counties with populations under 100,000 and a minimum increase of 10% for all other nonemergency secure behavioral health transport services.

The provisions of the act will become effective on January 1, 2026, allowing for preparatory administrative tasks to begin upon passage and approval.

Overall, these changes aim to enhance the financial viability of transport services for behavioral health, particularly in less populated areas.

The document presents an amendment to the Residential Mortgage License Act of 1987, focusing on a technical change to the section that outlines the short title of the Act. This adjustment is part of broader regulatory updates aimed at enhancing clarity within the residential mortgage industry.

The amendment seeks to ensure that the title under which the Act is cited is accurate and up-to-date. While the change is intended to improve the overall understanding of the Act, it does not specify any monetary impacts or particular dates for implementation.

Overall, the amendment reflects an effort to streamline and clarify the legislative framework governing residential mortgages.

AT A GLANCE

This bill appropriates biennial state budget funds for fiscal years beginning July 1, 2024 and July 1, 2025, and conditions their obligation and expenditure under statewide allotment, reporting, and program-expansion limits.

FULL SUMMARY

The bill makes biennial state budget appropriations covering the fiscal year beginning July 1, 2024 and the fiscal year beginning July 1, 2025 for operating expenses, state aid and obligations, capital outlay, debt service, and emergency/contingency, and it sets conditions for how appropriations may be obligated and expended. It establishes detailed funding amounts by branch and agency (legislative, judicial, and executive), including major departmental totals for programs such as courts, public defenders, attorney general functions, correctional facilities, education (K-12, higher education, and higher-ed capital maintenance), health and human services, TennCare, and transportation. It also incorporates the Department of Transportation’s “Proposed Highway Program for Fiscal Year 2025-2026” into the appropriations act and includes bridge-grant allocation and reporting requirements for project cancellations/rescheduling.

It authorizes carry-forward and non-reversion rules for capital outlay/major maintenance (e.g., certain capital appropriations remain available until expended; carry-forwards for major maintenance require commissioner approval based on general fund revenue/reserve availability). It creates or specifies earmarked appropriations and grant purposes (including multiple named grants and matching requirements), and establishes a regulatory/appropriations framework: (i) regulatory board operations must be allotted by the Commissioner of Finance and Administration before fee-based spending; (ii) Wildlife Resources Agency appropriations are tied to specific special funds and must be used only for agency purposes; (iii) the Department of Health must deposit fees or taxes it collects into the general fund, and its expenditures are subject to allotment approval; and (iv) appropriations from departmental revenues are generally available in addition to line-item appropriations unless otherwise provided.

The bill adds statewide budgeting controls and administrative authorities for state finance. Key provisions include: sum-sufficient appropriations for refunds of erroneous receipts and for certain debt service mechanics (including cancellation of unissued highway bonds and multiple earmarked debt service obligations); preferential payment rules if revenues are inadequate; restrictions on using appropriated funds for employee-targeted mass materials unless legislative information access is provided; and travel, conference, and compliance limitations. It also sets rules on appropriation allotments, reporting, and program expansion—no new or expanded programs beyond legislative scope unless funded entirely from unanticipated/excess federal or departmental revenues, and in many cases only after written notice to legislative finance leadership and acknowledgment.

The bill further includes specific programmatic budgeting directions and governance rules affecting education and health. For education, it imposes detailed constraints for the Tennessee Investment in Student Achievement (TISA) funding formula for fiscal year 2025-2026, including state share percentages, base dollar amounts per member student, restrictions on economically disadvantaged gap reduction, and capped appropriations for subcomponents (e.g., fast growth/infrastructure stipends, transition funding, distressed counties, teacher compensation disparity, and outcome bonuses). For TennCare, it authorizes transfers of federal and state health care funds into the TennCare program (with exceptions), allows carry-forward of unexpended TennCare appropriations from prior-year acts, permits use of certified public expenditures/intergovernmental transfers for federal matching, and includes service-limit authority and reporting deadlines on shared savings. Finally, it sets effective dates: July 1, 2025 generally, with some provisions effective immediately upon becoming law (including any items specifying immediate effectiveness), and it includes standard severability and supplemental appropriation/carry-forward provisions for prior-year balances and certain 2024-2025 additions.

The All Maine Health Act establishes an independent agency, All Maine Health, tasked with overseeing a comprehensive health care plan for all residents of Maine. This plan ensures that all residents are eligible for a wide range of health care services, including inpatient and outpatient care, mental health services, substance use disorder treatment, and preventive care. The Act also allows for nonresidents temporarily out of state and those employed in Maine to access the plan under specific conditions.

The All Maine Health Board has the authority to expand health care benefits beyond minimum requirements, provided sufficient funding is available. The plan will be funded through premiums based on income, federal funds, and other sources, with the establishment of the All Maine Health Fund to manage these finances. Minimal cost-sharing requirements may be imposed, and individuals can opt for private insurance for services not covered by the plan.

The Act emphasizes the importance of confidentiality regarding data collected from applicants and enrollees, while also allowing for necessary data sharing with providers and auditors. The board will establish payment systems for health care providers, ensuring that no balance billing occurs for covered services. An ombudsman will be appointed to advocate for consumers and address grievances.

Additionally, the agency will negotiate prices for pharmaceuticals and medical supplies to minimize costs and will collaborate with licensing agencies to monitor health care facilities. A program will be developed to support workers displaced by administrative efficiencies resulting from the plan, focusing on retraining and job placement in health care-related positions.

Overall, the All Maine Health Act aims to create a comprehensive health care system that impacts residents, health care providers, and businesses operating in or employing individuals from Maine, with a focus on accessibility, affordability, and quality of care.

The document outlines a legislative act that requires the Department of Health and Human Services to provide full reimbursement for emergency ambulance services to MaineCare members. This act affects various sectors, including municipal and quasi-municipal ambulance services, fire department emergency medical services, and private ambulance services.

Key provisions of the act stipulate that the department must reimburse providers at a rate considered usual, customary, and reasonable, in accordance with federal guidelines and state law. Additionally, the department is tasked with identifying and allocating sufficient funding from state and federal sources to meet these reimbursement requirements, with an emphasis on utilizing available federal matching funds.

Starting December 1, 2025, the department is also required to submit an annual report to the joint standing committee of the Legislature. This report will detail the number of services reimbursed, the total funds disbursed, and provide recommendations for enhancing reimbursement policies.

The changes will take effect with the implementation of the reimbursement requirements, which will be governed by rules adopted by the department as routine technical rules.

This document outlines amendments to the Texas Insurance Code that modify preauthorization requirements for health benefit plans, significantly impacting the health care industry, including health maintenance organizations (HMOs), insurers, physicians, and health care providers. The changes specifically address outpatient services, mental health care, substance use disorder treatment, and preventive health care services.

The legislation prohibits HMOs and insurers from requiring preauthorization for certain health care services, such as emergency care, necessary interventions, outpatient mental health treatment (with some exceptions), and preventive services recommended by the United States Preventive Services Task Force. This aims to streamline the preauthorization process and improve access to essential health care services for patients.

Additionally, the act seeks to prevent the denial or reduction of payments to physicians and providers for services that do not require preauthorization, unless there is evidence of misrepresentation or failure to perform the service. This could enhance financial stability for providers and potentially lower costs for patients.

Overall, these amendments are designed to facilitate better access to necessary health care services while reducing administrative burdens on providers and insurers in Texas.

The legislation seeks to address and reduce waiting lists for services under the Montana Medicaid program. It mandates the Department to implement various initiatives, which may include applying for Medicaid waivers, recalculating reimbursement rates, and providing additional funding for services experiencing waiting lists.

Key service areas affected by this legislation include senior and long-term care, behavioral health, dental services, family education and support services, and home-based and community-based services through the developmental disabilities program's Medicaid waiver.

The Department is also required to submit an annual report to the legislature that outlines the status of waiting lists, including the number of individuals affected, ongoing efforts to mitigate these lists, and projected timelines for their resolution.

Overall, the changes aim to enhance access to essential services for individuals enrolled in the Montana Medicaid program.

The 69th Legislature of Montana has introduced a bill that revises Medicaid services reimbursement, specifically affecting contracts with non-physician providers. One of the key changes mandates that these contracts include an annual cost of living adjustment provision.

Additionally, the fee for covered services provided by non-physician providers will be adjusted annually based on the percentage increase of the consumer price index for similar services, as determined by the Bureau of Labor Statistics.

These changes are set to take effect on July 1, 2025, and are expected to impact healthcare providers and businesses involved in Medicaid services. The legislation aims to ensure that reimbursement rates align with inflation and cost of living adjustments.

AT A GLANCE

This bill requires the Commission to Study Delivery Models for Emergency Medical Services to submit findings and recommendations for proposed legislation by November 1, 2025.

FULL SUMMARY

The bill establishes a new commission within New Hampshire government to study emergency medical services (EMS) delivery models statewide.

It adds a new subdivision to RSA 153-A establishing the “Commission to Study Delivery Models for Emergency Medical Services” and sets its membership: three House members appointed by the Speaker (with at least one member from each party and at least one representing Coos County), one Senate member appointed by the President, and eight appointed stakeholder/agency representatives (Department of Safety; New Hampshire Fire Chiefs Association; New Hampshire Ambulance Association; Professional Firefighters of New Hampshire; New Hampshire Hospital Association; New Hampshire Municipal Association; New Hampshire Association of Counties; and AHIP). Legislative members receive mileage at the legislative rate for commission duties.

The commission is directed to (1) review EMS delivery history and current municipal models; (2) review response systems for emergency calls, unscheduled emergency transfers, and non-emergency transfers; (3) identify barriers to EMS delivery, including rural access, interfacility transfers, and advanced life support provision; (4) assess which parts of the state could benefit from regional EMS care models; and (5) develop recommendations to support and build sustainable EMS systems. The commission elects a chair from among its members; the first meeting must be called by the first-named House member and held within 45 days of the section’s effective date. Four members constitute a quorum.

The commission must submit findings and recommendations for proposed legislation to multiple recipients—including the House and Senate leadership and clerks, the Governor, the state library, and the New Hampshire Historical Society—no later than November 1, 2025. The bill also repeals a prior existing EMS delivery commission statute (RSA 153-A:38 and its subdivision heading) and sets effective dates: the repeal takes effect November 1, 2025 (Section 2), while the rest takes effect upon passage.

The document outlines significant changes to reimbursement rates for public and school employee health benefit plans in Washington State, effective July 27, 2025. In-network hospitals will be reimbursed based on the lesser of billed charges, the contractor's contracted rate, or 200% of the total amount Medicare would have reimbursed for similar services. Special provisions apply to hospitals primarily caring for children in King County, which will have a reimbursement cap at 150% of the hospital-specific Medicaid inpatient ratio, and those in Pierce County, capped at 190%. Rural critical access hospitals will receive no less than 101% of allowable costs as defined by Medicare.

Reimbursement rates for in-network primary care services and non-facility-based behavioral health services will be set at no less than 150% of the total amount Medicare would have reimbursed. For out-of-network hospitals, reimbursement will be the lesser of billed charges or 185% of the total amount Medicare would have reimbursed, with specific adjustments for children's hospitals in King and Pierce counties.

Additionally, a report analyzing the impacts of these changes on network access, enrollee premiums, and state expenditures is required by December 31, 2030, with a follow-up report due by December 31, 2034. These changes are anticipated to significantly affect the healthcare industry, particularly hospitals and health carriers, by altering reimbursement structures and potentially influencing operational costs and patient care strategies.

The 132nd Maine Legislature's first regular session in 2025 has introduced a bill to amend reimbursement rates for ambulance services. The proposed changes will increase the reimbursement rate that insurance carriers must pay to ambulance service providers, setting it at either the provider's rate or 400% of the Medicare rate, whichever is less.

This adjustment is anticipated to have significant implications for the healthcare and insurance industries, particularly for those involved in emergency medical services. Additionally, the bill includes the repeal of certain previous provisions related to reimbursement rates.

The specific date for the implementation of these changes has not been provided.

The document outlines a series of significant amendments to Minnesota statutes that enhance health finance, policy, and regulations across various sectors, particularly healthcare, child welfare, and social services. Key provisions include the establishment of programs aimed at improving public awareness of dementia, enhancing maternal and child health services, and revising health licensing requirements. Additionally, the document addresses the need for education on signs of physical abuse in infants and the adjustment of regulations surrounding swing bed use in hospitals to improve capacity and streamline admissions.

In the realm of healthcare and pharmaceuticals, amendments focus on medication donation programs, pharmacy reimbursement structures, and transportation services. Stricter eligibility criteria for donated drugs and the establishment of a Formulary Committee are introduced to enhance the safety and efficiency of drug donations. Changes to reimbursement structures for pharmacies aim to improve transparency and accountability, while new regulations for dental services and nonemergency medical transportation seek to enhance access and service delivery for beneficiaries.

The document also emphasizes child welfare reforms, including new licensure and training requirements for foster care providers, and the establishment of a program for concurrent permanency planning to promote early stability for children in care. Amendments aim to improve the treatment and placement of children, ensuring that their needs are prioritized and that families are engaged in the process. Additionally, changes to reporting requirements for child neglect and maltreatment are introduced to enhance the effectiveness of local welfare agencies.

Significant funding allocations for fiscal years 2026 and 2027 are outlined, totaling approximately $1.3 billion, with a focus on health improvement, public health initiatives, and support services for families and children. These appropriations are designed to enhance the welfare of vulnerable populations, address emerging health trends, and improve access to essential services. The document reflects a comprehensive approach to funding and resource allocation across multiple sectors, aiming to support healthcare, social services, and child welfare initiatives in Minnesota.

Overall, these legislative changes represent a concerted effort to improve health services, enhance regulatory compliance, and support vulnerable populations while streamlining operational practices within the healthcare and social services systems.

The document outlines amendments to the Texas Government Code and Insurance Code concerning payment methods for claims made by health care providers to health maintenance organizations (HMOs) and managed care organizations. A significant change is the prohibition of requiring health care providers to accept claim payments via virtual credit cards or any payment method that incurs fees, with the exception of nominal fees from the provider's bank for electronic funds transfers.

Additionally, the amendments establish a timeline for payment, mandating that HMOs must pay providers for health care services within 45 days of receiving a claim with the necessary documentation, or within a timeframe specified in a written agreement.

These changes are set to take effect on September 1, 2025, impacting contracts entered into and claims submitted on or after that date. The amendments aim to enhance the financial operations of health care providers and organizations by eliminating certain payment methods that impose additional costs.

The 69th Legislature of Montana has introduced significant amendments to health insurance regulations, particularly focusing on the prior authorization process in health care. Key changes include extending the validity of prior authorization certifications to at least 12 months, with certifications for chronic conditions remaining valid for the duration of the condition. This aims to reduce the frequency of renewals and streamline access to necessary treatments.

Additionally, the amendments prohibit health insurance issuers from requiring prior authorization for certain prescription drugs, including specific generic medications, long-acting injectable antipsychotics, and drugs for substance use disorders, among others. These restrictions are designed to enhance patient access to essential medications and reduce administrative barriers.

The changes will impact various sectors, including health insurance providers, health care providers, and pharmaceutical companies, necessitating adjustments in operational processes and reimbursement practices. While specific financial implications are not detailed, the amendments may lead to increased operational costs for insurers due to the need for revised protocols and training.

Overall, the revisions aim to improve transparency in health care decision-making and facilitate better access to necessary health care services for patients. The effective date for these amendments has not been specified.

AT A GLANCE

This bill requires utilization review entities to grant or issue adverse determinations for urgent health-care services within 24 hours and to notify providers within the same deadline.

FULL SUMMARY

The bill changes Delaware’s health insurance pre-authorization law by strengthening requirements on utilization review for both health insurance contracts (Title 18, Chapter 33, Subchapter II) and group/blanket health insurance plans (Title 18, Chapter 35, Subchapter V). It also directs the State Employee Benefits Committee to ensure carriers comply for group health insurance plans and requires state health agencies (to the extent feasible) to include these pre-authorization provisions in certain post-effective-date Medicaid-related carrier contracts.

Key changes include: (1) modifying definitions to include “Episode of Care” limitations (including that it is not out-of-network care) and defining “Urgent health-care service” as an expedited prior-authorization service for acute conditions where delay is likely to cause serious long-term complications or material deterioration; (2) tightening standards for who can make adverse determinations and appeal determinations (including non-contingent compensation for reviewers, licensing/qualification requirements, and prohibitions on direct involvement for appeal reviewers); (3) requiring utilization review entities to provide appeal outcome notices within specified timelines and to include required content in written notices when additional information is needed; and (4) imposing operational requirements on utilization review entities (weekend review, access to a clinical decision maker during defined hours, available appeal submission channels, and a minimum 30-day appeal submission window after an adverse determination).

The bill shortens and refines pre-authorization decision timelines for non-emergency and urgent services. For non-emergency pharmaceutical pre-authorization, a utilization review entity must act or issue an adverse determination and notify the provider within 2 business days after obtaining a “clean” pre-authorization (or after using services specified in the relevant electronic-filing section). For non-urgent health-care services, decision/notice deadlines are reduced to 5 business days for electronic pre-authorization and 8 business days for non-electronic pre-authorization (with “clean” including any required face-to-face evaluation/second opinion). For urgent health-care services, the deadline for granting or issuing an adverse determination and notifying the provider is 24 hours. Patient transfer prior-authorization deadlines are similarly set at 24 hours (for electronic) and 48 hours (for non-electronic), with a notable exception allowing medically necessary interfacility transport without pre-authorization when a lower level of care is clinically appropriate.

It also changes the validity and scope of pre-authorization: a pre-authorization for a health-care service must be valid for at least 90 days (up from 60 days), may not exceed one pre-authorization per episode of care (with separate pre-authorization potentially required for unrelated new treatments/tests), and—when pre-authorization is granted for one service in a bundled-payment group—pre-authorization for other in-network covered services in the same group is deemed approved. The bill further strengthens electronic pre-authorization requirements by requiring insurers/utilization review entities to accept and respond to electronic pre-authorization requests through the same submission method by no later than January 1, 2027, and by requiring a provider portal with specified features; providers can be required to submit through the portal after portal establishment within 12 months, subject to defined exemptions. The act applies to policies/contracts/certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2026.

The State of Vermont has enacted legislation to amend Medicaid payment rates for community-based service providers, affecting sectors such as long-term care, home health, hospice services, and support for individuals with mental health conditions, substance use disorders, and developmental disabilities.

The Secretary of Human Services is responsible for calculating payment rates that are reasonable and adequate to meet the needs of the populations served. This process will take into account the costs associated with governmental mandates, inflation, and labor market conditions. A methodology for determining these rates will be established, including regular studies on Medicaid reimbursement rates every five years.

Additionally, the Secretary will create a process for providers facing imminent closure to request stabilization support. Payment rates will be recalculated annually, with reports on these rates and necessary funding submitted to relevant legislative committees.

The Agency of Human Services is required to provide an update on the implementation of these changes by January 15, 2026, outlining the schedule for Medicaid rate studies and the methodology for calculating payment rates. The act takes effect upon passage, following the Governor's approval on May 13, 2025.

The new legislation in Alaska establishes minimum provider network standards for health care insurers, requiring them to consider these standards when calculating benefits for policies that utilize limited networks of health care providers.

Insurers must include all licensed hospitals, skilled nursing facilities, and mental health or substance abuse facilities in their networks, along with all licensed physicians, physician assistants, and advanced practice registered nurses associated with these facilities. Additionally, insurers are mandated to maintain a sufficient number of providers in each region to meet specific minimum network standards, which differ by location.

For instance, insurers in the Municipality of Anchorage are required to include at least 70% of actively practicing providers in each specialty, while those in other regions may need to include up to 80%. Insurers can request temporary exceptions to these standards for a maximum of 36 months, provided they submit compliance plans and annual progress reports.

The changes are set to take effect on January 1, 2026, and are expected to influence the health insurance industry, health care providers, and potentially the costs associated with health care coverage in Alaska.

The document outlines changes to Medicaid reimbursement policies for nursing facilities in Texas that occur after a change in ownership. Under the new provisions, nursing facilities providing Medicaid services will continue to receive uninterrupted reimbursement if they meet specific criteria, including enrollment as a provider under Medicare and Medicaid and compliance with state law requirements.

A key requirement is the establishment of a successor liability agreement, which mandates that the new ownership assumes responsibility for any outstanding liabilities identified by the commission, including those incurred by the previous owner. However, these changes do not apply to supplemental or directed payment programs operated by the commission.

The new policies will take effect on September 1, 2025, primarily impacting nursing facilities that provide Medicaid services. While specific monetary impacts are not detailed, the requirement for new owners to assume outstanding liabilities could have significant financial implications for these facilities.

The document outlines a legislative act designed to improve the reimbursement process for critical access hospitals participating in the Montana Medicaid program. It addresses the delays in settling cost reports, which have been worsened by the current practice of waiting for Medicare's final desk audits before finalizing Medicaid reimbursements.

The primary industry affected by this act is healthcare, particularly critical access hospitals that provide essential medical services to communities in Montana. By ensuring timely and accurate reimbursement for services rendered, the act aims to alleviate financial strain on these hospitals, thereby improving their cash flow.

The act establishes a process for tentative retroactive adjustments and interim settlements, which are intended to enhance fiscal management for critical access hospitals. It seeks to align Montana Medicaid's reimbursement practices with those of Medicare, ultimately providing better support for these healthcare facilities.

Overall, the act represents a significant step toward improving the financial stability of critical access hospitals in Montana, ensuring they receive timely reimbursements for the services they provide to their communities.

The document outlines significant amendments to Minnesota Statutes that impact various sectors, including healthcare, social services, housing assistance, and child welfare. Key provisions aim to enhance program integrity and service delivery, particularly through changes in funding and operational practices for the Departments of Human Services, Health, and Children, Youth, and Families. These amendments introduce new laws and modify existing statutes, leading to adjustments in financial allocations and compliance requirements across affected industries.

In the healthcare sector, the amendments impose new fees on health maintenance organizations and provider-based clinics to improve transparency regarding facility fees. Hospitals are now required to conduct public hearings on major operational changes, while new reporting requirements for drug manufacturers and pharmacies aim to increase transparency in drug pricing. The legislation also emphasizes mental health services, focusing on early intervention and individualized treatment plans for children with emotional disturbances.

The amendments further address housing assistance by adjusting eligibility standards for adults under 65, particularly those transitioning from institutions, while ensuring that individuals over 65 can maintain their benefits. In child welfare, the legislation enhances the administration of child protection services with stricter licensing and training requirements for foster care providers, emphasizing family engagement and regular court reviews of out-of-home placements. The establishment of the African American Child Well-Being Advisory Council aims to improve outcomes for African American children in the welfare system.

Additionally, the amendments introduce new training requirements for child care providers and establish a Quality Parenting Initiative Grant Program to support families in foster care. Financial allocations for fiscal years 2026 and 2027 reflect a commitment to improving mental health services, child welfare systems, and support programs, with significant funding designated for initiatives such as school-linked behavioral health services and community-based support for HIV/AIDS.

Overall, these amendments represent a comprehensive effort to reform and modernize state statutes, enhancing the quality and accessibility of services across healthcare, social services, and education in Minnesota, ultimately ensuring better support for families and individuals in need.

The document outlines significant amendments to Minnesota statutes that aim to enhance healthcare, support services, and the overall quality of life for individuals with disabilities and vulnerable populations. Key changes include increased surcharges for nursing homes, new appeal processes for providers, and adjustments to payment models that consider wage standards for nursing home employees. Additionally, funding for nutrition support services will be expanded to include meal transportation and outreach efforts, while essential community supports will target seniors and individuals with dementia.

Amendments also focus on improving disability services through comprehensive training programs for service providers and families, as well as streamlining assessment procedures for individuals receiving home and community-based waiver services. Changes to targeted case management for autism spectrum disorder and developmental disabilities will establish new reporting metrics and payment structures, ensuring a qualified workforce to support these individuals. Furthermore, the consolidation of disability waiver programs aims to create individualized budgets tailored to specific needs.

In the realm of mental health and substance use disorder treatment, the document introduces new eligibility requirements for behavioral health fund payments and emphasizes the importance of compliance and oversight for treatment providers. Funding appropriations are allocated for various initiatives, including mobile crisis grants and long-term care services, reflecting a commitment to improving access to care and support for individuals facing mental health challenges.

The document also addresses housing support and emergency shelter facilities, establishing supplementary service rates to enhance financial support for providers. While some funding reductions are noted in specific areas, the overall approach emphasizes a comprehensive strategy to improve services across healthcare, housing, and social assistance programs.

Overall, these amendments and appropriations are designed to significantly impact the healthcare and social services landscape in Minnesota, enhancing the availability and effectiveness of support services for individuals with disabilities and ensuring compliance with new qualifications and assessment standards.

The document outlines changes to the eligibility for mediation of certain out-of-network health benefit claims in Texas, primarily impacting the health care and insurance industries. These changes specifically affect out-of-network providers and health benefit plan issuers or administrators.

Under the new provisions, out-of-network providers or health benefit plan issuers can request mandatory mediation regarding payment for health care services or supplies. This development is expected to influence financial negotiations and settlements between the involved parties.

The changes will apply to health care services or supplies provided on or after the 30th day following the effective date of the Act. For services rendered before this period, mediation can be requested if initiated by the relevant parties within 120 days after the Act's effective date.

The Act will take effect immediately if it receives a two-thirds vote from all elected members of each house; otherwise, it will take effect on September 1, 2025.