VirginiaHB12842026 Regular SessionHouseWALLET

State plan for medical assistance; provider-to-provider consultation.

Sponsored By: Mark C. Downey (Democratic)

Became Law

Summary

Department of Medical Assistance Services; state plan for medical assistance; provider-to-provider consultation; telemedicine. Specifies that the Medicaid provision for provider-to-provider consultation includes payment for consultations provided through telemedicine services. This bill incorporates HB 87.

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Bill Overview

Analyzed Economic Effects

16 provisions identified: 13 benefits, 1 costs, 2 mixed.

Medicaid covers transplants and high-dose cancer care

If you are over 21 and on Medicaid, Medicaid pays for liver, heart, and lung transplants when strict medical rules are met, including prior authorization. The transplant cannot be investigational, must be likely to prolong life and restore function, and current therapy must have failed. You cannot be in an irreversible terminal state. Medicaid also covers high-dose chemotherapy and bone marrow transplants for adults with lymphoma, breast cancer, myeloma, or leukemia when your doctor confirms your performance status is adequate. If coverage is denied, you can use the Department's expedited appeals process.

More coverage for medical devices and equipment

Medicaid pays for a custom ocular prosthesis when medically needed. If you live in a nursing facility, Medicaid pays for the initial purchase or replacement of a complex manual or power wheelchair and accessories. You pay no deductibles, copays, or coinsurance. Your clinician must sign and return the certificate of medical necessity and supporting documents to the DME supplier within 60 days after the equipment is first furnished.

New specialized care for children and brain injuries

Medicaid pays for rapid whole genome sequencing for children age three or younger in an ICU. Labs must return preliminary positive results within 7 days and final results within 15 days. Medicaid covers testing and treatment for PANS and PANDAS when clinical definitions are met, including antimicrobials, medications, behavioral therapy, immunomodulating drugs, plasma exchange, and IVIG. People who meet program criteria for severe traumatic brain injury get targeted case management to coordinate care and services.

Women's cancer screening and treatment coverage

If you were screened through the CDC program and need treatment for breast or cervical cancer, Medicaid pays if you are under 65, lack creditable coverage, and are not otherwise eligible. Medicaid covers one Pap smear each year. It covers low-dose screening mammograms: one at ages 35–39, every two years at 40–49, and every year at 50 and over. After a radical or modified radical mastectomy, at least 48 hours in the hospital are covered; after a total or partial with lymph node removal, at least 24 hours, unless you and your doctor choose a shorter stay. Medicaid pays for prostheses after mastectomy and for breast reconstruction after medically necessary removal. Breast reductions are covered with prior authorization. These procedures are not treated as cosmetic.

More Medicaid help before and after birth

Medicaid covers pregnancy care for recent lawful residents during their first five years in the U.S., if they meet pregnancy eligibility rules. Pregnant enrollees get comprehensive dental care with at least four visits, and more if a dentist or OB recommends. Medicaid covers up to 10 doula visits (up to 4 before birth and up to 6 in the 12 months after). It pays for remote ultrasounds and at-home fetal non-stress tests when secure, FDA-approved tech is used and billed for home monitoring. Postpartum inpatient care and doctor-recommended home visits are covered based on leading perinatal guidelines. Family planning services are covered for 24 months after delivery if you still meet pregnant-woman financial rules. Medicaid does not pay for abortion services or referrals. You can get up to a 12-month supply of self-administered hormonal birth control at one time unless a medical reason prevents it.

Easier Medicaid access and care for kids

The state uses one form to apply for FAMIS Plus and the FAMIS Plan for medically indigent children. Medicaid pays for newborn hearing screening with FDA‑approved tools and for follow‑up exams a physician, physician assistant, nurse practitioner, or audiologist recommends. Follow‑up testing must be done by a licensed audiologist. Children from birth through age three who are certified as eligible for Part C early‑intervention services can be exempt from mandatory Medicaid managed‑care enrollment. The agency sets and follows the procedures for this exception.

Faster contracts for special-needs care

The Director can make tailored contracts for Medicaid recipients with special needs, including people with AIDS and ventilator‑dependent patients. These contracts are exempt from the Virginia Public Procurement Act, except the subdivision A 1 exception in § 2.2‑4345, and must follow federal rules. The Board issues rules for these patients.

Long-term care partnership for seniors

When federal law allows, the state establishes a long‑term care partnership program through a Medicaid plan amendment. If you buy a qualified private long‑term care policy under this program, some of your assets can be protected for Medicaid eligibility, as federal rules allow. Asset treatment and estate recovery follow federal guidance.

More Medicaid support for kids and students

Medicaid pays for medical care for people under 21 placed by licensed private child-placing agencies or through state or local subsidized adoptions, as federal law allows. For Medicaid-eligible youth under 21, medically necessary inpatient acute care days beyond 21 days per admission are covered. Schools can bill Medicaid for health services they provide to Medicaid-enrolled students, with or without an IEP, including telemedicine. Providers do not have to use proprietary technology to get paid.

Quick Medicaid updates to match federal law

The Board can update the Medicaid state plan to match changes in the Social Security Act, other federal laws or rules, court orders, or HHS guidance so federal funding continues. It can make these changes without full rulemaking, but must notify the Registrar of Regulations or certify to the Governor that the change is required.

Telehealth and remote monitoring coverage grows

Medicaid pays for medically necessary care by telemedicine no matter where you are or if someone is with you. Remote patient monitoring is covered for listed groups, including high-risk pregnancy, medically complex kids, transplant patients, people up to three months after surgery, and patients with two or more recent hospital or ER visits when monitoring can prevent readmission. Doctors can be paid for provider-to-provider consults, including by telemedicine, on terms no more restrictive than fee-for-service. EMS agencies get an originating site fee when they help run a live telehealth visit at the patient's location, such as home, work, school, or a medical facility.

Adult children help pay parents' care

The Board seeks federal approval to set up a family assistance program. Under it, children over age 18 make reasonable contributions, set by Board rules, toward their parents’ medical assistance costs. The Board sets the amounts and how payments work.

Eligibility protections for assets and spouses

When you set aside money for burial, Medicaid ignores up to $3,500 for you and up to $3,500 for your spouse. These amounts are reduced by life insurance face value and by other burial trusts or contracts. Your main home is not counted. For people under AFDC-dependent rules, that includes all contiguous property. For others, nearby land is ignored only if its extra-land value is $5,000 or less. If you are in an institution, Medicaid can deduct an amount from your income to help support a spouse who lives at home.

Felon providers removed from Medicaid

Medicaid ends any provider contract when the provider is convicted of a felony. The Director can refuse to enter, renew, or can terminate contracts with providers who are convicted or excluded under 42 C.F.R. Part 1002.

Prostate and colon cancer screening covered

Medicaid covers one PSA test every 12 months and digital rectal exams for people age 50 and over, and for those 40 and over at high risk under American Cancer Society guidance. It also covers colorectal screening per professional guidelines, including annual stool blood tests, sigmoidoscopy, colonoscopy, or imaging. Your age and risk decide how often.

Stronger Medicaid provider rules and payments

The Medicaid Board prepares and updates the state plan with the Governor's approval, works with the State Board of Health to protect quality and patient rights, starts cost-saving steps in the budget, and includes federal nursing-home penalties in state rules. Before publishing rules with local fiscal impact, the Board shares analyses with local social services boards. Agencies that take Medicaid applications must collect the applicant's best address and phone and give information on advance directives. The Department issues prescription or health benefit cards and reissues or sends corrected data when needed so prescriptions process electronically. Pharmacists under collaborative agreements and several licensed behavioral health clinicians are reimbursed for covered services. The Department uses electronic funds transfer to pay when practical. If a provider's contract is denied or ended, the provider can appeal in writing within 15 days and get a hearing; the Director may weigh harm to recipients when setting exclusion length and may reinstate providers under federal rules.

Sponsors & Cosponsors

Sponsor

Mark C. Downey
Democratic • House

Cosponsors

There are no cosponsors for this bill.

Roll Call Votes

All Roll Calls

Yes: 264 • No: 0

Senate vote • 3/10/2026

Passed Senate Block Vote

Yes: 40 • No: 0

Senate vote • 3/9/2026

Constitutional reading dispensed Block Vote (on 2nd reading)

Yes: 40 • No: 0

Senate vote • 3/9/2026

Passed by for the day Block Vote (Voice Vote)

Yes: 0 • No: 0

Senate vote • 3/6/2026

Reported from Finance and Appropriations

Yes: 14 • No: 0

Senate vote • 2/26/2026

Reported from Education and Health and rereferred to Finance and Appropriations

Yes: 15 • No: 0

House vote • 2/13/2026

Read third time and passed House Block Vote

Yes: 96 • No: 0

House vote • 2/9/2026

Reported from Appropriations

Yes: 22 • No: 0

House vote • 2/6/2026

Subcommittee recommends reporting

Yes: 7 • No: 0 • Other: 1

House vote • 2/3/2026

Reported from Health and Human Services with substitute and referred to Appropriations