2020 Session

Budget Amendments - SB30 (Committee Approved)

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Medicaid Coverage of Innovative Drugs & Emerging Technologies (language only)

Item 313 #32s

Item 313 #32s

Health and Human Resources
Department of Medical Assistance Services


Page 321, after line 18, insert:

"GGGG.  The Department of Medical Assistance Services shall develop a process to appropriately handle the determination of Medicaid coverage and reimbursement of FDA fast-track drugs and emerging-break-through technologies. This process shall include (i) a determination of whether the Virginia Medicaid program will cover the drug or technology; (ii) upon determination of coverage, a determination of uniform clinical criteria for coverage; (iii) upon determination of clinical criteria for coverage, mandated application of the clinical criteria for coverage across Fee-For-Service and Managed Care Organizations; and (iv) the development of an actuarially-sound reimbursement methodology for Managed Care Organizations to include kick-payments or other pass-through arrangements consistent with the utilization and cost of the drug or technology. This process shall apply to FDA-approved break-through technologies covered beginning in Medicaid plan year 2020. Implementation of the process should not exceed four months from the date of the FDA approval of the drug or technology and determination by the department that coverage is required."


(This amendment adds language requiring the Department of Medical Assistance Services (DMAS) to develop a process for coverage and reimbursement of emerging technologies and innovative drugs that are approved by the Food and Drug Administration and required to be covered by DMAS.)