AT A GLANCE

This bill permits network-plan pharmacists and pharmacies, beginning January 1, 2026, to decline items or services when reimbursement falls below acquisition cost and requires administrative organizations to provide contracts within three calendar days.

AT A GLANCE

This bill requires the Department to base pharmacy benefits manager reimbursement on NADAC or discounted wholesale cost, calculate savings by July 1, 2026, and reinvest them in dispensing fees.

AT A GLANCE

This bill establishes a parental right to home-educate children, generally without declarations or assessments, and requires pharmacy benefit managers to secure carrier agreements and annually report rebate data.

Section 9C of Chapter 118E of the Massachusetts General Laws would be amended by adding a requirement that all MassHealth managed care organizations and accountable care organizations reimburse pharmacies at the rate specified in the MassHealth Pharmacy Provider Manual. The Commissioner of Insurance and the Secretary of Health and Human Services would be required to promulgate regulations enforcing this requirement, as provided on page 2.

The bill eliminates the MNsure board’s annual reporting requirement under Minnesota Statutes, section 62V.05, subdivision 7(d). The board would no longer have to submit, beginning March 15, 2016, and each March 15 thereafter, reports to specified legislative committee members concerning interagency agreements, including each agreement’s agency, duration, purpose, terms, and—when practicable—a copy of the agreement.

Beginning in 2026, the Maryland Department of Health must conduct the in-State cost-of-dispensing survey at least once every three years. In each year the survey is conducted, the Department must report the results to the General Assembly by December 1, in accordance with § 2-1257 of the State Government Article.

The provision that would have required the Department to adopt regulations establishing a fee-for-service professional dispensing fee based on the survey results within six months after completion of the survey was deleted from the enacted measure (page 1). The Act takes effect October 1, 2026.

Beginning in 2026, the Maryland Department of Health must conduct the in-State cost-of-dispensing survey at least once every three years. In each year the survey is conducted, the Department must report the survey results to the General Assembly by December 1, in accordance with § 2-1257 of the State Government Article. The Act does not establish the proposed fee-for-service professional dispensing fee requirement shown in the legislative text. It takes effect October 1, 2026.

AT A GLANCE

This bill requires the Auditor General to study Medicaid prescription-drug management and report findings by March 31, 2027, while requiring related private entities to provide unredacted records.

AT A GLANCE

This act requires the auditor general to independently study whether consolidating Medicaid prescription drug management would benefit Rhode Island and submit findings, recommendations, and proposed legislation by March 31, 2027.

The bill adds enforcement authority concerning Medicaid pharmacy access. Pharmacy benefit managers (PBMs) must accept and process Medicaid prescriptions from any pharmacy or pharmacist in good standing with the Department of Health and the State Board of Pharmacy. PBMs may not restrict, limit, or otherwise control the pharmacies available to Medicaid patients based solely on the PBM’s private contracting preferences. The provision takes effect 60 days after enactment.

The document outlines upcoming changes to pharmacy dispensing fees in Nebraska, primarily impacting independent pharmacies and those participating in the medical assistance program. Effective July 1, 2026, independent pharmacies will receive a reimbursement of ten dollars and thirty-eight cents per prescription.

For other pharmacies, the reimbursement will vary based on the volume of prescriptions filled. Pharmacies with fewer than thirty thousand prescriptions per year will also receive ten dollars and thirty-eight cents per prescription. Those filling between thirty thousand and fewer than seventy thousand prescriptions will receive nine dollars and fifty-one cents, while pharmacies with seventy thousand or more prescriptions will receive eight dollars and thirty cents per prescription. Additionally, pharmacies that are the only enrolled pharmacy within a thirty-mile radius will be reimbursed at the rate of ten dollars and thirty-eight cents per prescription.

To ensure fair reimbursement, a cost-of-dispensing survey is to be completed by July 1, 2026, with recommendations for annual adjustments to pharmacy dispensing fees. A preliminary report with recommendations is due by December 15, 2024. These changes aim to provide adequate support for pharmacies involved in the medical assistance program.

AT A GLANCE

This bill requires PBMs and managed care organizations to reimburse community pharmacies at least NADAC, or WAC when unavailable, plus the statutory dispensing fee, and prohibits below-standard reductions through fees or adjustments.

AT A GLANCE

This bill requires PBMs and managed care organizations to reimburse community pharmacies at least NADAC, or WAC if unavailable, plus the statutory dispensing fee, and prohibits below-cost reductions.

The secretary of the Executive Office of Health and Human Services must ensure that managed care organizations and pharmacy benefit managers serving Rhode Island’s Medicaid program operate transparently, avoid unnecessary costs, and demonstrate improved patient health outcomes. Contracts with managed care organizations must require pharmacy benefit managers to cease and prohibit spread pricing, defined as charging a health plan more for a prescription drug than the amount reimbursed to the pharmacy and retaining the difference.

The act takes effect upon passage.

AT A GLANCE

This bill requires pharmacy benefit managers to reimburse non-affiliated pharmacies and pharmacists at least the net effective rate paid to affiliated providers for the same drug or service.

AT A GLANCE

This bill requires Medicaid managed care organizations and their pharmacy benefit managers to reimburse non-affiliated pharmacies or pharmacists at least the net effective reimbursement paid to affiliated providers for identical Medicaid drugs or services, barring evasive arrangements.

AT A GLANCE

This bill requires the Maryland Department of Health, by July 1, 2028, to select and contract with a single third-party administrator as the State pharmacy benefits manager for all Medical Assistance recipients.

AT A GLANCE

This bill requires Pennsylvania’s Department of Human Services to select and contract with one third-party administrator as the State pharmacy benefits manager for all Medicaid pharmacy benefits by July 31, 2026.

AT A GLANCE

This bill appropriates approximately $202.5 billion for Virginia state operations and capital projects during the biennium beginning July 1, 2026, funding agencies, programs, positions, and debt service.

The bill adds provisions requiring the Agency for Health Care Administration to conduct a fiscal impact study on implementing discounted drug prices under the 340B Drug Pricing Program. The study must include specific requirements related to drug pricing, rebates, and payments to pharmacy benefit managers, with the results due by January 31, 2027. This change applies to drugs on the Medicaid preferred drug list that are covered under the 340B program. Definitions needed for this provision include the "340B Drug Pricing Program" and the "Medicaid preferred drug list."

AT A GLANCE

This bill requires the Department of Human Services to select and contract with a single state pharmacy benefits manager for all Medicaid pharmacy benefits by July 31, 2026.

AT A GLANCE

This bill requires pharmacy benefits managers, beginning July 1, 2027, to reimburse eligible pharmacies at national average drug acquisition cost plus Georgia’s Medicaid dispensing fee, with a wholesale-cost fallback.

AT A GLANCE

This bill requires managed care organizations and pharmacy benefits managers to use DMAS-standardized methodologies to report detailed drug spending and rebate data to DMAS and CMS for public disclosure.

AT A GLANCE

This bill requires the Department of Medical Assistance Services, by July 1, 2026, to select and contract with a single pharmacy benefits manager for all Medicaid pharmacy benefits.

The bill repeals Section 3 of Act 4, Special Session Laws of Hawaii 2005, which prohibits the Department of Human Services from taking action to remove pharmaceutical benefits management from managed care plans providing health coverage to Hawaii Medicaid beneficiaries. This removes that statutory restriction and permits the department to evaluate and implement pharmaceutical benefits management arrangements for the med-QUEST program. The Act takes effect July 1, 3000.

The document outlines the establishment of a Patient-Centered Care program in Minnesota, designed to enhance health outcomes and reduce healthcare costs. A key feature of the program is the authorization for direct payments to licensed healthcare providers for services rendered to medical assistance and MinnesotaCare enrollees, focusing on individual providers and clinics rather than hospital systems. Additionally, primary care providers will receive compensation for coordinating care, with provisions for patients to select their care coordinators and additional support for clinics serving populations facing health disparities.

To support vulnerable populations, the program includes funding for community health clinics and county-based purchasers to hire community health workers and deliver outreach and care coordination services. The commissioner of human services, in collaboration with the commissioner of health, is also tasked with developing a payment system that provides per-person care coordination payments to licensed health care homes and community health workers, particularly for individuals requiring intensive care coordination.

The document emphasizes the importance of cost neutrality in implementing care coordination payments, with potential reallocations within the healthcare system if initial savings are insufficient. Furthermore, it highlights the need for federal waivers and approvals to implement various health care initiatives, including the expansion of demonstration projects to include more enrollees from medical assistance and MinnesotaCare, as well as Medicare recipients and privately insured individuals.

Integrated health partnerships may be authorized to provide patient incentives for engaging in preventive health measures, fostering ongoing relationships with primary care providers. Overall, these initiatives are expected to significantly impact the healthcare industry, particularly in areas related to care coordination, community health services, and patient engagement strategies.

AT A GLANCE

This bill requires the Chief Procurement Officer to procure a single pharmacy benefit manager for the medical assistance program and Medicaid managed care organizations within one year after the Act’s effective date, managing pharmacy claims beginning January 1, 2028.

The bill changes Oklahoma Medicaid reimbursement requirements by making the Oklahoma Health Care Authority’s establishment of minimum reimbursement rates discretionary, rather than mandatory, until July 1, 2027. It also makes discretionary the requirement that rates for providers outside contracted-entity networks meet at least 100% of the applicable Authority fee-schedule rate for participating in-network providers or 90% of the applicable January 1, 2021 fee-schedule rate for nonparticipating or out-of-network providers. The act takes effect November 1, 2026.

Beginning July 1, 2026, Medicaid eligibility is expanded to individuals under age 65 who are not pregnant, are not entitled to or enrolled in Medicare Part A or Part B, are not covered under another Medicaid eligibility category, and have household income no greater than 133% of the applicable federal poverty level. Eligibility will be determined by the Division of Medicaid, and coverage for this group is limited to essential health benefits under the federal Patient Protection and Affordable Care Act. This eligibility category is repealed December 31, 2028.

Beginning July 1, 2026, Medicaid must provide ACA essential health benefits to individuals eligible under this new category, but only while the federal Medicaid matching percentage for services to the population remains at or above 90%. This coverage provision is also repealed December 31, 2028. The act takes effect July 1, 2026.

The bill changes Medicaid adverse-determination appeals by expressly recognizing psychologists as appropriate appeal reviewers for services within their expertise. A psychologist reviewer must be currently licensed under Oklahoma’s Psychologists Licensing Act and have training and experience in testing or treating the condition, or sufficient expertise to determine whether the service is medically necessary or clinically appropriate. The reviewer must also satisfy the existing independence, licensing, specialty, financial-interest, and clinical-record review requirements.

The Oklahoma Health Care Authority must establish a reimbursement rate for psychologists whose appeals under the revised process are successful. The payment must compensate for the hours spent handling the appeal, including time that otherwise would have been used to provide patient services. The act becomes effective November 1, 2026.

AT A GLANCE

This bill requires pharmacy benefit managers and covered entities to permit only qualifying drugs on MAC lists, update them every three business days, and reimburse pharmacies for covered medications at least their acquisition cost.

AT A GLANCE

This bill establishes a State PBM within DHS upon CMS approval of Hawaii’s Medicaid state plan and requires Medicaid managed care organizations to use it for beneficiaries’ pharmacy benefits.

AT A GLANCE

This bill requires Medicaid to reimburse prescription drugs in fee-for-service and managed-care programs at least at national average acquisition cost plus the $10.92 dispensing fee, subject to federal law.

The bill repeals sections 1 and 1-a of Part FFF of Chapter 56 of the Laws of 2020, which directed the Department of Health to remove the pharmacy benefit from the managed care benefit package and provide that benefit through the fee-for-service program. The act takes effect immediately.

AT A GLANCE

This bill requires Medicaid managed care organizations’ pharmacy benefit managers to reimburse brand and generic drugs from pharmacies with no more than seven outlets at specified lesser amounts when acquisition-cost prices are unavailable.

AT A GLANCE

This bill requires pharmacy benefit managers and covered entities to limit MAC lists to qualifying drugs, update them every three business days, and reimburse pharmacies at or above acquisition cost.

The document outlines significant amendments to Minnesota Statutes that impact healthcare, environmental services, and child welfare. Key changes include increased licensing and registration fees for health maintenance organizations and new requirements for well disclosure certificates, which mandate property sellers to disclose known well locations. Healthcare providers will face enhanced reporting obligations related to drug pricing and telehealth services, while stricter regulations for occupational therapy and midwifery practices emphasize education and ethical standards.

In the healthcare sector, a county-administered program aims to integrate healthcare and social services in rural communities, improving access to care. Changes to reimbursement structures for various healthcare providers, including adjustments for telehealth and nonemergency medical transportation, are also highlighted. Additionally, the document addresses child welfare reforms that focus on improving support systems for children in foster care and enhancing engagement with noncustodial parents, including detailed transition plans for youth aging out of the system.

The amendments also introduce significant changes to child care and mental health services. Enhanced security measures for licensed child care centers, such as mandatory video surveillance, and regular eligibility assessments for families receiving child care assistance are key highlights. In the mental health sector, initiatives like the Mental Health Collaboration Hub Pilot Project and targeted funding for crisis intervention services aim to improve care pathways for individuals facing mental health challenges.

Further appropriations for health and human services include substantial funding for General Assistance, Emergency General Assistance, and Minnesota Supplemental Aid Grants, with a focus on mental health services, substance use treatment, and public health initiatives. Additional funding is allocated for early childhood education, literacy programs, scholarships, and youth intervention initiatives, as well as emergency medical services to enhance training and operational capabilities.

Overall, these amendments and funding allocations reflect a comprehensive effort to enhance regulatory frameworks, improve service delivery, and address disparities across multiple sectors in Minnesota, with a strong emphasis on accountability, transparency, and the well-being of vulnerable populations.

The document outlines significant amendments to Minnesota Statutes concerning human services, particularly focusing on the procurement and management of a state pharmacy benefit manager. These changes primarily impact the healthcare and pharmaceutical industries, including managed care plans, pharmacy benefit managers, and licensed pharmacies in Minnesota. A competitive procurement process is mandated for selecting a single pharmacy benefit manager, which may alter the operational and financial dynamics of these entities.

Additionally, the amendments empower the commissioner of human services to modify prescription drug coverage to enhance state savings through increased collection of drug rebates. Contracts with managed care plans are required to incentivize cost management and may incorporate provisions for preferred drug lists and prior authorization, potentially affecting drug reimbursement rates and fees.

The document also introduces new disclosure and reporting requirements for state pharmacy benefit managers and managed care plans regarding prescription drug payments and pricing. Pharmacy benefit managers must disclose all payment sources for prescribed drugs and provide quarterly reports detailing negotiated prices, rebates, and savings passed on to managed care enrollees. Managed care plans are similarly required to disclose their administrative costs related to pharmacy services.

Furthermore, the commissioner is granted authority to develop a preferred drug list, negotiate prices with drug manufacturers, and manage a drug formulary for managed care plans. The commissioner may also review contracts between pharmacy benefit managers and pharmacies to ensure compliance with the new regulations.

Overall, these amendments aim to enhance the management of prescription drug costs and improve the efficiency of the pharmacy benefit system within Minnesota's healthcare framework.

The document describes the creation of a prescription drug purchasing program in Minnesota, which will be overseen by the commissioner of human services. The primary goal of this program is to provide medical assistance and MinnesotaCare enrollees with access to prescription drugs at the lowest possible prices. The commissioner will be responsible for negotiating discounts on prescription drugs, maintaining a list of effective medications, and managing the associated benefits.

This initiative is expected to have significant implications for the pharmaceutical industry, particularly affecting drug manufacturers, wholesalers, and pharmacies. The commissioner will negotiate prices and establish a preferred drug list, with pharmacies required to accept the terms set forth to participate as medical assistance providers.

The program's implementation is contingent upon federal approval and is scheduled to begin on January 1, 2027, or upon receiving that approval, whichever occurs later. Furthermore, the commissioner is also tasked with developing recommendations to expand the program to include enrollees from health plan companies, with a deadline for these recommendations set for December 15, 2027.

The document outlines the establishment of a Patient-Centered Care program in Minnesota, aimed at improving health outcomes and reducing healthcare costs. A key feature of the program is the authorization for direct payments to licensed healthcare providers for services rendered to medical assistance and MinnesotaCare enrollees, focusing on individual providers and clinics rather than hospital systems.

The program emphasizes care coordination by compensating primary care providers for their role in coordinating care for enrollees. Patients will have the option to select a primary care provider as their care coordinator, with additional fees allocated to clinics serving populations facing health disparities. Community outreach will be enhanced through grants to community health clinics and county-based purchasers, enabling the hiring of community health workers to deliver essential services to vulnerable populations.

The commissioner of human services, in collaboration with the commissioner of health, will develop a new payment system for care coordination services, which will vary fees based on the complexity of care required. This system aims to address the needs of patients with limited English skills and other barriers to healthcare access while ensuring cost neutrality in its implementation.

Additionally, the document discusses the expansion of health care programs and the establishment of accountable care organizations. The commissioner will seek federal waivers and approvals to implement these initiatives, which include expanding demonstration projects to encompass more enrollees and potentially integrating services for Medicare recipients and privately insured individuals.

Overall, the changes aim to enhance care coordination and access to health services for vulnerable populations, while also incentivizing preventive health measures through integrated health partnerships. The initiatives are expected to significantly impact the healthcare industry, particularly managed care organizations and primary care providers.

The document outlines significant amendments to Minnesota Statutes concerning the management of prescription drug coverage within the state's human services programs. A key change is the requirement for the commissioner of human services to select a single state pharmacy benefit manager (PBM) through a competitive procurement process. This initiative aims to enhance cost savings for the state by increasing prescription drug rebates and effectively managing drug costs.

The amendments will impact several business industries, including pharmacy benefit managers, pharmacies, and health plans. The selected PBM will be responsible for processing all pharmacy claims and managing drug coverage for managed care plans. Pharmacies licensed in Minnesota may encounter new fees and assessments imposed by the PBM, potentially affecting their operational costs and profitability. Additionally, health plans and county-based purchasing organizations will need to comply with the new requirements established in the master contract with the state PBM.

The document also introduces new disclosure and reporting requirements for state pharmacy benefit managers and managed care plans regarding prescription drug payments and pricing. PBMs must disclose all sources of payment for prescribed drugs, including rebates and discounts, and provide quarterly reports detailing negotiated prices, payments to pharmacies, and savings passed on to managed care enrollees. Managed care plans are required to disclose their administrative costs related to pharmacy services.

Furthermore, the commissioner has the authority to develop a preferred drug list, negotiate prices with drug manufacturers, and manage a drug formulary for managed care plans. The commissioner may also review contracts between PBMs and pharmacies to ensure compliance with the new regulations.

These changes are set to take effect in 2024, with the new regulations for disclosure and reporting scheduled to begin on January 1, 2027, or upon receiving necessary federal approvals.

The proposed legislation amends the Oklahoma Medicaid program by establishing capitated contracts for the delivery of Medicaid services, excluding dental and prescription drug services. The Oklahoma Health Care Authority (OHCA) will issue requests for proposals to create public-private partnerships aimed at serving various Medicaid populations, including pregnant women, children, and parents. The new program is set to be implemented by April 1, 2024, with dental services being covered through partnerships with dental benefit managers and prescription drug services transitioning to a fee-for-service model.

Key provisions include requirements for contracted entities to share patient data with providers and to refrain from enforcing restrictive contracting policies. Additionally, minimum reimbursement rates for providers not participating in value-based payment arrangements will be established, ensuring that network providers receive at least 100% of the applicable service fee and non-network providers receive 90%. The Authority will also set minimum rates for Certified Community Behavioral Health Clinic (CCBHC) providers and ensure adequate reimbursement for ground transportation services.

Contracted entities are mandated to offer value-based payment arrangements tied to quality metrics and must allocate at least 11% of total healthcare expenses to primary care services by the end of the fourth year of the initial contracting period. The changes are expected to impact various business industries, including healthcare providers, pharmacies, and behavioral health clinics, with potential financial implications related to reimbursement rates and contractual obligations.

Overall, the legislation aims to enhance the efficiency and effectiveness of Medicaid services in Oklahoma, focusing on provider-led and provider-owned entities while promoting value-based care and improved patient outcomes.