WEST VIRGINIA LEGISLATURE
2024 REGULAR SESSION
Committee Substitute for Senate Bill 444
BY SENATORS DEEDS, SMITH, STOVER, STUART,
WOELFEL, BARRETT, ROBERTS, AND TAKUBO
[Originating in the Committee on Health and Human Resources; reported February 2, 2024]
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1 A BILL to amend and reenact §33-15-21 of the Code of West Virginia, 1931, as amended; to
2 amend and reenact §33-16-3i of said code; to amend and reenact §33-24-7e of said code;
3 to amend and reenact §33-25-8d of said code; and to amend and reenact §33-25A-8d of
4 said code, all relating to health insurance coverage for emergency services; providing
5 coverage mandates for ground ambulance services when a prudent layperson acting
6 reasonably would have believed that an emergency medical condition existed; providing
7 that covered services include pre-hospital screening and stabilization of emergency
8 conditions by an ambulance service; providing that air ambulance service is excluded from
9 coverage; providing that coverage is subject to deductibles or copayment requirements of
10 the policy, contract, or plan; and providing that coverage be provided if the patient declines
11 to be transported against medical advice.
Be it enacted by the Legislature of West Virginia:
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-21. Coverage of emergency services.
1 From July 1, 1998:
2 (a) Every insurer shall provide coverage for emergency medical services, including
3 prehospital services, to the extent necessary to screen and to stabilize an emergency medical
4 condition. The insurer shall not require prior authorization of the screening services if a prudent
5 layperson acting reasonably would have believed that an emergency medical condition existed.
6 Prior authorization of coverage shall not be required for stabilization if an emergency medical
7 condition exists. Payment of claims for emergency services shall be based on the retrospective
8 review of the presenting history and symptoms of the covered person.
9 (b) The coverage for prehospital screening and stabilization of an emergency medical
10 condition shall include ambulance services provided under the provisions of §16-4C-1 et seq. of
11 this code, excluding air ambulance services as defined in §16-4C-3(a) of this code. The insurer
12 shall pay claims for prehospital screening and stabilization of emergency condition by ambulance
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13 service if the insured is transported to an emergency room of a facility provider or if the patient
14 declines to be transported against medical advice. The coverage under this section is subject to
15 deductibles or copayment requirements of the policy, contract, or plan.
16 (b) (c) An insurer that has given prior authorization for emergency services shall cover the
17 services and shall not retract the authorization after the services have been provided unless the
18 authorization was based on a material misrepresentation about the covered person's health
19 condition made by the referring provider, the provider of the emergency services, or the covered
20 person.
21 (c) (d) Coverage of emergency services shall be subject to coinsurance, copayments, and
22 deductibles applicable under the health benefit plan.
23 (d) (e) The emergency department and the insurer shall make a good faith effort to
24 communicate with each other in a timely fashion to expedite post evaluation or post stabilization
25 services in order to avoid material deterioration of the covered person's condition.
26 (e) (f) As used in this section:
27 (1) "Emergency medical services" means those services required to screen for or treat an
28 emergency medical condition until the condition is stabilized, including prehospital care;
29 (2) "Prudent layperson" means a person who is without medical training and who draws
30 on his or her practical experience when making a decision regarding whether an emergency
31 medical condition exists for which emergency treatment should be sought;
32 (3) "Emergency medical condition for the prudent layperson" means one that manifests
33 itself by acute symptoms of sufficient severity, including severe pain, such that the person could
34 reasonably expect the absence of immediate medical attention to result in serious jeopardy to the
35 individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious
36 impairment to bodily functions; or serious dysfunction of any bodily organ or part;
37 (4) "Stabilize" means with respect to an emergency medical condition, to provide medical
38 treatment of the condition necessary to assure, with reasonable medical probability, that no
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39 medical deterioration of the condition is likely to result from or occur during the transfer of the
40 individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or
41 otherwise delay the transportation required for a higher level of care than that possible at the
42 treating facility;
43 (5) "Medical screening examination" means an appropriate examination within the
44 capability of the hospital's emergency department, including ancillary services routinely available
45 to the emergency department, to determine whether or not an emergency medical condition
46 exists; and
47 (6) "Emergency medical condition" means a condition that manifests itself by acute
48 symptoms of sufficient severity, including severe pain, such that the absence of immediate
49 medical attention could reasonably be expected to result in serious jeopardy to the individual's
50 health, or, with respect to a pregnant woman, the health of the unborn child, serious impairment
51 to bodily functions, or serious dysfunction of any bodily part or organ.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS COVERAGE.
§33-16-3i. Coverage of emergency services.
1 (a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to
2 which this article applies, any entity regulated by this article shall provide as benefits to all
3 subscribers and members coverage for emergency services. A policy, provision, contract, plan,
4 or agreement may apply to emergency services the same deductibles, coinsurance, and other
5 limitations as apply to other covered services: Provided, that preauthorization or precertification
6 shall not be required.
7 (b) From July 1, 1998, the following provisions apply:
8 (1) Every insurer shall provide coverage for emergency medical services, including
9 prehospital services, to the extent necessary to screen and to stabilize an emergency medical
10 condition. The insurer shall not require prior authorization of the screening services if a prudent
11 layperson acting reasonably would have believed that an emergency medical condition existed.
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12 Prior authorization of coverage shall not be required for stabilization if an emergency medical
13 condition exists. Payment of claims for emergency services shall be based on the retrospective
14 review of the presenting history and symptoms of the covered person.
15 (2) The coverage for prehospital screening and stabilization of an emergency medical
16 condition shall include ambulance services provided under the provisions of §16-4C-1 et seq. of
17 this code, excluding air ambulance services as defined in §16-4C-3(a) of this code. The insurer
18 shall pay claims for prehospital screening and stabilization of emergency condition by ambulance
19 service if the insured is transported to an emergency room of a facility provider or if the patient
20 declines to be transported against medical advice. The coverage under this section is subject to
21 deductibles or copayment requirements of the policy, contract, or plan.
22 (2) (3) An insurer that has given prior authorization for emergency services shall cover the
23 services and shall not retract the authorization after the services have been provided unless the
24 authorization was based on a material misrepresentation about the covered person's health
25 condition made by the referring provider, the provider of the emergency services, or the covered
26 person.
27 (3) (4) Coverage of emergency services shall be subject to coinsurance, copayments, and
28 deductibles applicable under the health benefit plan.
29 (4) (5) The emergency department and the insurer shall make a good faith effort to
30 communicate with each other in a timely fashion to expedite post evaluation or post stabilization
31 services in order to avoid material deterioration of the covered person's condition.
32 (5) (6) As used in this section:
33 (A) "Emergency medical services" means those services required to screen for or treat an
34 emergency medical condition until the condition is stabilized, including prehospital care;
35 (B) "Prudent layperson" means a person who is without medical training and who draws
36 on his or her practical experience when making a decision regarding whether an emergency
37 medical condition exists for which emergency treatment should be sought;
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38 (C) "Emergency medical condition for the prudent layperson" means one that manifests
39 itself by acute symptoms of sufficient severity, including severe pain, such that the person could
40 reasonably expect the absence of immediate medical attention to result in serious jeopardy to the
41 individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious
42 impairment to bodily functions; or serious dysfunction of any bodily organ or part;
43 (D) "Stabilize" means with respect to an emergency medical condition, to provide medical
44 treatment of the condition necessary to assure, with reasonable medical probability, that no
45 medical deterioration of the condition is likely to result from or occur during the transfer of the
46 individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or
47 otherwise delay the transportation required for a higher level of care than that possible at the
48 treating facility;
49 (E) "Medical screening examination" means an appropriate examination within the
50 capability of the hospital's emergency department, including ancillary services routinely available
51 to the emergency department, to determine whether or not an emergency medical condition
52 exists; and
53 (F) "Emergency medical condition" means a condition that manifests itself by acute
54 symptoms of sufficient severity, including severe pain, such that the absence of immediate
55 medical attention could reasonably be expected to result in serious jeopardy to the individual's
56 health, or, with respect to a pregnant woman, the health of the unborn child, serious impairment
57 to bodily functions or serious dysfunction of any bodily part or organ.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH
SERVICE CORPORATIONS.
§33-24-7e. Coverage of emergency services.
1 (a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to
2 which this article applies, any entity regulated by this article shall provide as benefits to all
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3 subscribers and members coverage for emergency services. A policy, provision, contract, plan,
4 or agreement may apply to emergency services the same deductibles, coinsurance, and other
5 limitations as apply to other covered services: Provided, That preauthorization or precertification
6 shall not be required.
7 (b) From July 1, 1998, the following provisions apply:
8 (1) Every insurer shall provide coverage for emergency medical services, including
9 prehospital services, to the extent necessary to screen and to stabilize an emergency medical
10 condition. The insurer shall not require prior authorization of the screening services if a prudent
11 layperson acting reasonably would have believed that an emergency medical condition existed.
12 Prior authorization of coverage shall not be required for stabilization if an emergency medical
13 condition exists. Payment of claims for emergency services shall be based on the retrospective
14 review of the presenting history and symptoms of the covered person.
15 (2) The coverage for prehospital screening and stabilization of an emergency medical
16 condition shall include ambulance services provided under the provisions of §16-4C-1 et seq. of
17 this code, excluding air ambulance services as defined in §16-4C-3(a) of this code. The insurer
18 shall pay claims for prehospital screening and stabilization of emergency condition by ambulance
19 service if the insured is transported to an emergency room of a facility provider or if the patient
20 declines to be transported against medical advice. The coverage under this section is subject to
21 deductibles or copayment requirements of the policy, contract, or plan.
22 (2) (3) An insurer that has given prior authorization for emergency services shall cover the
23 services and shall not retract the authorization after the services have been provided unless the
24 authorization was based on a material misrepresentation about the covered person's health
25 condition made by the referring provider, the provider of the emergency services, or the covered
26 person.
27 (3) (4) Coverage of emergency services shall be subject to coinsurance, copayments, and
28 deductibles applicable under the health benefit plan.
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29 (4) (5) The emergency department and the insurer shall make a good faith effort to
30 communicate with each other in a timely fashion to expedite post evaluation or post stabilization
31 services in order to avoid material deterioration of the covered person's condition.
32 (5) (6) As used in this section:
33 (A) "Emergency medical services" means those services required to screen for or treat an
34 emergency medical condition until the condition is stabilized, including prehospital care;
35 (B) "Prudent layperson" means a person who is without medical training and who draws
36 on his or her practical experience when making a decision regarding whether an emergency
37 medical condition exists for which emergency treatment should be sought;
38 (C) "Emergency medical condition for the prudent layperson" means one that manifests
39 itself by acute symptoms of sufficient severity, including severe pain, such that the person could
40 reasonably expect the absence of immediate medical attention to result in serious jeopardy to the
41 individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious
42 impairment to bodily functions; or serious dysfunction of any bodily organ or part;
43 (D) "Stabilize" means with respect to an emergency medical condition, to provide medical
44 treatment of the condition necessary to assure, with reasonable medical probability, that no
45 medical deterioration of the condition is likely to result from or occur during the transfer of the
46 individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or
47 otherwise delay the transportation required for a higher level of care than that possible at the
48 treating facility;
49 (E) "Medical screening examination" means an appropriate examination within the
50 capability of the hospital's emergency department, including ancillary services routinely available
51 to the emergency department, to determine whether or not an emergency medical condition
52 exists; and
53 (F) "Emergency medical condition" means a condition that manifests itself by acute
54 symptoms of sufficient severity, including severe pain, such that the absence of immediate
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55 medical attention could reasonably be expected to result in serious jeopardy to the individual's
56 health, or, with respect to a pregnant woman, the health of the unborn child, serious impairment
57 to bodily functions, or serious dysfunction of any bodily part or organ.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-8d. Coverage of emergency services.
1 (a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to
2 which this article applies, any entity regulated by this article shall provide as benefits to all
3 subscribers and members coverage for emergency services. A policy, provision, contract, plan,
4 or agreement may apply to emergency services the same deductibles, coinsurance, and other
5 limitations as apply to other covered services: Provided, That preauthorization or precertification
6 shall not be required.
7 (b) From July 1, 1998, the following provisions apply:
8 (1) Every insurer shall provide coverage for emergency medical services, including
9 prehospital services, to the extent necessary to screen and to stabilize an emergency medical
10 condition. The insurer shall not require prior authorization of the screening services if a prudent
11 layperson acting reasonably would have believed that an emergency medical condition existed.
12 Prior authorization of coverage shall not be required for stabilization if an emergency medical
13 condition exists. Payment of claims for emergency services shall be based on the retrospective
14 review of the presenting history and symptoms of the covered person.
15 (2) The coverage