VirginiaHB4812026 Regular SessionHouseWALLET

Prior authorization; requiring physician review for denial.

Sponsored By: Patrick A. Hope (Democratic)

Became Law

Summary

Prior authorization; requiring physician review for denial. Prohibits a health insurance carrier from making an adverse determination of a prior authorization request (i) for prescription drugs unless such denial has been reviewed and approved by a licensed physician or, if a licensed physician is not available, by a licensed pharmacist or (ii) for health care services unless such adverse determination has been reviewed and approved by (a) a licensed physician; (b) in the case of mental health services, a licensed mental health provider if a licensed physician is unavailable; or (c) in the case of dental services, a licensed dentist if a licensed physician is unavailable.

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Bill Overview

Analyzed Economic Effects

10 provisions identified: 7 benefits, 2 costs, 1 mixed.

No take-backs after service approval

Beginning January 1, 2027, once a prior authorization for services is approved and care is scheduled or provided as approved, the insurer cannot revoke or limit it. Exceptions are if the provider asks to change it, there is fraud or misrepresentation, or a federal regulator or manufacturer pulls or limits the service for safety. The rule does not require authorization if you are no longer enrolled.

Some plans excluded from drug rules

The drug prior-authorization protections do not apply to Medicare, Medicaid, CHIP, the Federal Employees Health Benefits program, or TRICARE, and to several limited‑benefit plans (like accident‑only, disability, long‑term care, dental, and vision). Certain HMOs that meet listed integrated and interoperability rules may also be excluded. These exclusions apply until January 1, 2027.

Doctor review before drug denials

A drug prior authorization cannot be denied unless a licensed physician reviews and approves the denial. If no physician is available, a licensed pharmacist may review drug denials. This clinical review rule applies now and continues on and after January 1, 2027.

Doctor review before service denials

Beginning January 1, 2027, a denial of prior authorization for medical services must be reviewed and approved by a licensed physician. If no physician is available, a licensed mental health provider may review mental health service denials, and a licensed dentist may review dental denials.

Faster approvals for medical services

Beginning January 1, 2027, urgent prior authorization requests for medical services get a response within 72 hours, including weekends. Standard requests get an answer within seven calendar days. If more information is required, the insurer must say exactly what is needed and then decide within the 72‑hour or seven‑day limit after complete info is sent.

Faster drug approvals and real-time costs

Starting July 1, 2025, insurers run an online prior authorization system that links to e‑prescribing and EHRs and shows real-time out‑of‑pocket costs. They must accept requests by phone, fax, or approved electronic systems, and can auto‑approve some requests when no extra review is needed. Urgent drug requests get a reply within 24 hours, including weekends; standard, fully complete requests get an answer within two business days. If more info is needed, the insurer must say exactly what from the record is needed and decide within two business days after it is sent. Insurers must give a tracking ID, explain any denial, and post formularies, PA lists, procedures, and forms in one place online (updated within seven days). No one can be charged a fee to use the online process. These drug rules apply until January 1, 2027.

Keep your medicine covered during changes

If you switch plans, your new insurer must honor a prior authorization from your old plan for the first 90 days when your prescriber sends proof. If you change plans within the same insurer, it must honor the old approval as long as the drug is still a covered benefit. A prior approval stays valid for non‑opioid drugs when your prescriber changes the dose within FDA‑labeled limits. Insurers generally cannot revoke an approved drug authorization after the drug was scheduled or given, except for fraud, new safety or regulatory actions, serious interactions, or a new generic/biosimilar. Mental health drugs that are covered, at FDA doses, used for at least three continuous months, and reviewed yearly by your prescriber do not need a new PA; at least one covered substance use treatment drug must be available without PA if it follows FDA and Board rules. In some cases, an approval must be honored even if a drug is later removed from the formulary. These drug protections apply until January 1, 2027.

Public lists and 30 day notice for approvals

Beginning January 1, 2027, insurers must post a public web page listing services and codes that need prior authorization, how to request it, and effective dates, and update it by each change’s effective date. Providers must get at least 30 days’ notice before changes take effect. In a pandemic, disaster, or other emergency, insurers can remove prior authorization right away. Each year by March 31, insurers must post plan‑level prior authorization data for the prior year. If the insurer did not post the rules for your date of service, it cannot deny your claim for missing prior authorization.

New e-prescribing tech rules for providers

Starting July 1, 2025, providers must ensure their e‑prescribing or EHR system can connect to each insurer’s online prior authorization and real-time benefit tools at the point of prescribing. Providers can ask for a waiver if this causes undue hardship. Carriers cannot use the online process to access provider data beyond the enrollee’s data without the provider’s consent. By July 1, 2024, carriers must share contact info for any third‑party vendor they use (posting it online counts). This mandate ends January 1, 2027.

Some integrated HMOs exempt in 2027

Beginning January 1, 2027, if your HMO contracts with an employed multispecialty physician group and provides care through that group or contracted community providers, the new service prior-authorization rules in this section do not apply to that plan.

Sponsors & Cosponsors

Sponsor

  • Patrick A. Hope

    Democratic • House

Cosponsors

There are no cosponsors for this bill.

Roll Call Votes

All Roll Calls

Yes: 317 • No: 1

House vote 3/10/2026

Senate substitute agreed to by House

Yes: 98 • No: 1

Senate vote 3/5/2026

Commerce and Labor Substitute agreed to

Yes: 0 • No: 0

Senate vote 3/5/2026

Passed Senate with substitute Block Vote

Yes: 39 • No: 0

Senate vote 3/4/2026

Constitutional reading dispensed Block Vote (on 2nd reading)

Yes: 39 • No: 0

Senate vote 3/4/2026

Passed by for the day Block Vote (Voice Vote)

Yes: 0 • No: 0

Senate vote 3/2/2026

Reported from Commerce and Labor with substitute

Yes: 13 • No: 0

House vote 2/4/2026

Read third time and passed House

Yes: 97 • No: 0

House vote 1/29/2026

Reported from Labor and Commerce with substitute

Yes: 22 • No: 0

House vote 1/27/2026

Subcommittee recommends reporting with substitute

Yes: 9 • No: 0 • Other: 1

Actions Timeline

  1. Fiscal Impact Statement from State Corporation Commission (HB481)

    4/13/2026House
  2. Acts of Assembly Chapter text (CHAP0925)

    4/13/2026Governor
  3. Approved by Governor-Chapter 925 (effective 7/1/2026)

    4/13/2026Governor
  4. Governor's Action Deadline 11:59 p.m., April 13, 2026

    3/31/2026Governor
  5. Enrolled Bill communicated to Governor on March 31, 2026

    3/31/2026House
  6. Signed by Speaker

    3/31/2026House
  7. Bill text as passed House and Senate (HB481ER)

    3/30/2026House
  8. Enrolled

    3/30/2026House
  9. Signed by President

    3/30/2026Senate
  10. Senate substitute agreed to by House (98-Y 1-N 0-A)

    3/10/2026House
  11. Passed by for the day

    3/9/2026House
  12. Fiscal Impact Statement from State Corporation Commission (HB481)

    3/5/2026House
  13. Passed Senate with substitute Block Vote (39-Y 0-N 0-A)

    3/5/2026Senate
  14. Commerce and Labor Substitute agreed to

    3/5/2026Senate
  15. Engrossed by Senate - committee substitute

    3/5/2026Senate
  16. Read third time

    3/5/2026Senate
  17. Passed by for the day Block Vote (Voice Vote)

    3/4/2026Senate
  18. Constitutional reading dispensed Block Vote (on 2nd reading) (39-Y 0-N 0-A)

    3/4/2026Senate
  19. Rules suspended

    3/4/2026Senate
  20. Committee substitute printed 26108765D-S1

    3/3/2026Senate
  21. Senate committee offered

    3/2/2026Senate
  22. Reported from Commerce and Labor with substitute (13-Y 0-N)

    3/2/2026Senate
  23. Referred to Committee on Commerce and Labor

    2/5/2026Senate
  24. Constitutional reading dispensed (on 1st reading)

    2/5/2026Senate
  25. Read third time and passed House (97-Y 0-N 0-A)

    2/4/2026House

Bill Text

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