The third enactment clause of Chapters 58 and 68 of the 2025 Acts of Assembly directs the State Corporation Commission (Commission), in coordination with the Secretary of Health and Human Resources (SHHR), to convene a stakeholder work group to:

(i) monitor anticipated federal developments related to the implementation of (metrics reporting) requirements to make … information pertaining to prior authorization for health care services1 (publicly available) consistent with the provisions of § 38.2-3407.15:8 of the Code of Virginia (Code)…; (ii) assess industry progress and readiness to implement such requirements; and (iii) evaluate policies supporting the effective and efficient adoption of such requirements.

The work group sought to ensure consistent metrics reporting requirements in support of a unified and transparent prior authorization protocol across both public and private health insurance markets. To this end, it makes the following key findings and recommendations:

Key Findings

The work group finds that Virginia’s prior authorization metrics reporting requirements in § 38.2-3407.15:8 of the Code, for carriers providing health care services in the private commercial market, promote a unified reporting process and mirror by reference those adopted at the federal level for impacted payers2 providing medical items and services, as prescribed in 42 C.F.R §§ 422.122(c), 438.210(f), 440.230(e)(3), and 457.732(c); and related regulations.

The work group is unaware of any major federal rules proposed or adopted that would build upon, add to, or subtract from the corresponding metrics reporting requirements delineated in the Virginia law. However, the Centers for Medicare and Medicaid Services (CMS) has since published a reporting template and overview for voluntary use by payers.

The work group finds that Virginia’s private commercial health carriers appear ready and able to implement Virginia’s reporting mandate as currently constituted. No specific challenges or impediments were identified by work group participants.

Key Recommendations

The work group recommends no changes to § 38.2-3407.15:8 of the Code related to reporting requirements.

The work group recommends that interested stakeholders continue to monitor federal activities related to prior authorization metrics in the event future revisions to the federal requirements warrant updates to Virginia’s law.