WEST VIRGINIA LEGISLATURE
2024 REGULAR SESSION
Introduced House Bill 4869
By Delegates Statler, Summers, Mallow,
Burkhammer, Jennings, Toney, Ellington, Riley,
Barnhart, Butler, and Petitto [Introduced January 17, 2024; Referred to the Committee on Banking and Insurance then the Judiciary]
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1 A BILL to amend and reenact §33-15-21, §33-16-3i, §33-24-7e, §33-25-8d, and §33-25A-8d of the
2 Code of West Virginia, 1931, as amended; relating to clarifying that health insurance
3 coverage for emergency services when a prudent layperson acting reasonably would have
4 believed that an emergency medical condition existed includes prehospital screening and
5 stabilization of emergency condition by ambulance service if the patient declines to be
6 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 §16-4-1, et seq. of
11 this code. The insurer shall pay claims for prehospital screening and stabilization of emergency
12 condition by ambulance service if the insured is transported to an emergency room of a facility
13 provider or if the patient declines to be transported against medical advice.
14 (b) (c) An insurer that has given prior authorization for emergency services shall cover the
15 services and shall not retract the authorization after the services have been provided unless the
16 authorization was based on a material misrepresentation about the covered person's health
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17 condition made by the referring provider, the provider of the emergency services or the covered
18 person.
19 (c) (d) Coverage of emergency services shall be subject to coinsurance, copayments and
20 deductibles applicable under the health benefit plan.
21 (d) (e) The emergency department and the insurer shall make a good faith effort to
22 communicate with each other in a timely fashion to expedite postevaluation or poststabilization
23 services in order to avoid material deterioration of the covered person's condition.
24 (e) (f) As used in this section:
25 (1) "Emergency medical services" means those services required to screen for or treat an
26 emergency medical condition until the condition is stabilized, including prehospital care;
27 (2) "Prudent layperson" means a person who is without medical training and who draws on
28 his or her practical experience when making a decision regarding whether an emergency medical
29 condition exists for which emergency treatment should be sought;
30 (3) "Emergency medical condition for the prudent layperson" means one that manifests
31 itself by acute symptoms of sufficient severity, including severe pain, such that the person could
32 reasonably expect the absence of immediate medical attention to result in serious jeopardy to the
33 individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious
34 impairment to bodily functions; or serious dysfunction of any bodily organ or part;
35 (4) "Stabilize" means with respect to an emergency medical condition, to provide medical
36 treatment of the condition necessary to assure, with reasonable medical probability that no
37 medical deterioration of the condition is likely to result from or occur during the transfer of the
38 individual from a facility: Provided, That this provision may not be construed to prohibit, limit or
39 otherwise delay the transportation required for a higher level of care than that possible at the
40 treating facility;
41 (5) "Medical screening examination" means an appropriate examination within the
42 capability of the hospital's emergency department, including ancillary services routinely available
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43 to the emergency department, to determine whether or not an emergency medical condition
44 exists; and
45 (6) "Emergency medical condition" means a condition that manifests itself by acute
46 symptoms of sufficient severity including severe pain such that the absence of immediate medical
47 attention could reasonably be expected to result in serious jeopardy to the individual's health or
48 with respect to a pregnant woman the health of the unborn child, serious impairment to bodily
49 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 or
4 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 §16-4-1, et seq. of
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17 this code. The insurer shall pay claims for prehospital screening and stabilization of emergency
18 condition by ambulance service if the insured is transported to an emergency room of a facility
19 provider or if the patient declines to be transported against medical advice.
20 (2) (3) An insurer that has given prior authorization for emergency services shall cover the
21 services and shall not retract the authorization after the services have been provided unless the
22 authorization was based on a material misrepresentation about the covered person's health
23 condition made by the referring provider, the provider of the emergency services or the covered
24 person.
25 (3) (4) Coverage of emergency services shall be subject to coinsurance, copayments and
26 deductibles applicable under the health benefit plan.
27 (4) (5) The emergency department and the insurer shall make a good faith effort to
28 communicate with each other in a timely fashion to expedite postevaluation or poststabilization
29 services in order to avoid material deterioration of the covered person's condition.
30 (5) (6) As used in this section:
31 (A) "Emergency medical services" means those services required to screen for or treat an
32 emergency medical condition until the condition is stabilized, including prehospital care;
33 (B) "Prudent layperson" means a person who is without medical training and who draws on
34 his or her practical experience when making a decision regarding whether an emergency medical
35 condition exists for which emergency treatment should be sought;
36 (C) "Emergency medical condition for the prudent layperson" means one that manifests
37 itself by acute symptoms of sufficient severity, including severe pain, such that the person could
38 reasonably expect the absence of immediate medical attention to result in serious jeopardy to the
39 individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious
40 impairment to bodily functions; or serious dysfunction of any bodily organ or part;
41 (D) "Stabilize" means with respect to an emergency medical condition, to provide medical
42 treatment of the condition necessary to assure, with reasonable medical probability that no
4
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43 medical deterioration of the condition is likely to result from or occur during the transfer of the
44 individual from a facility: Provided, That this provision may not be construed to prohibit, limit or
45 otherwise delay the transportation required for a higher level of care than that possible at the
46 treating facility;
47 (E) "Medical screening examination" means an appropriate examination within the
48 capability of the hospital's emergency department, including ancillary services routinely available
49 to the emergency department, to determine whether or not an emergency medical condition
50 exists; and
51 (F) "Emergency medical condition" means a condition that manifests itself by acute
52 symptoms of sufficient severity including severe pain such that the absence of immediate medical
53 attention could reasonably be expected to result in serious jeopardy to the individual's health or
54 with respect to a pregnant woman the health of the unborn child, serious impairment to bodily
55 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
3 subscribers and members coverage for emergency services. A policy, provision, contract, plan or
4 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
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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 §16-4-1, et seq. of
17 this code. The insurer shall pay claims for prehospital screening and stabilization of emergency
18 condition by ambulance service if the insured is transported to an emergency room of a facility
19 provider or if the patient declines to be transported against medical advice.
20 (2) (3) An insurer that has given prior authorization for emergency services shall cover the
21 services and shall not retract the authorization after the services have been provided unless the
22 authorization was based on a material misrepresentation about the covered person's health
23 condition made by the referring provider, the provider of the emergency services or the covered
24 person.
25 (3) (4) Coverage of emergency services shall be subject to coinsurance, copayments and
26 deductibles applicable under the health benefit plan.
27 (4) (5) The emergency department and the insurer shall make a good faith effort to
28 communicate with each other in a timely fashion to expedite postevaluation or poststabilization
29 services in order to avoid material deterioration of the covered person's condition.
30 (5) (6) As used in this section:
31 (A) "Emergency medical services" means those services required to screen for or treat an
32 emergency medical condition until the condition is stabilized, including prehospital care;
33 (B) "Prudent layperson" means a person who is without medical training and who draws on
34 his or her practical experience when making a decision regarding whether an emergency medical
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35 condition exists for which emergency treatment should be sought;
36 (C) "Emergency medical condition for the prudent layperson" means one that manifests
37 itself by acute symptoms of sufficient severity, including severe pain, such that the person could
38 reasonably expect the absence of immediate medical attention to result in serious jeopardy to the
39 individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious
40 impairment to bodily functions; or serious dysfunction of any bodily organ or part;
41 (D) "Stabilize" means with respect to an emergency medical condition, to provide medical
42 treatment of the condition necessary to assure, with reasonable medical probability that no
43 medical deterioration of the condition is likely to result from or occur during the transfer of the
44 individual from a facility: Provided, That this provision may not be construed to prohibit, limit or
45 otherwise delay the transportation required for a higher level of care than that possible at the
46 treating facility;
47 (E) "Medical screening examination" means an appropriate examination within the
48 capability of the hospital's emergency department, including ancillary services routinely available
49 to the emergency department, to determine whether or not an emergency medical condition
50 exists; and
51 (F) "Emergency medical condition" means a condition that manifests itself by acute
52 symptoms of sufficient severity including severe pain such that the absence of immediate medical
53 attention could reasonably be expected to result in serious jeopardy to the individual's health or
54 with respect to a pregnant woman the health of the unborn child, serious impairment to bodily
55 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
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3 subscribers and members coverage for emergency services. A policy, provision, contract, plan or
4 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 §16-4-1, et seq. of
17 this code. The insurer shall pay claims for prehospital screening and stabilization of emergency
18 condition by ambulance service if the insured is transported to an emergency room of a facility
19 provider or if the patient declines t