The proposed bill seeks to amend the Code of West Virginia by introducing provisions that address surprise billing for out-of-network ambulance services, effective for health insurance policies issued on or after January 1, 2026. It establishes that payments made by insurers to nonparticipating emergency medical services agencies for covered ground ambulance services will be considered full payment, excluding any copayments, coinsurance, deductibles, or other cost-sharing amounts required from the insured. Additionally, nonparticipating providers are prohibited from billing the insured for any amounts beyond what the insurer requires them to pay. The bill also mandates that insurers remit payment directly to these agencies within 30 days of receiving a clean claim and outlines the necessary procedures for claim denial notifications.

Moreover, the bill specifies that insurers must pay non-participating emergency medical services agencies at a rate of either 400 percent of the current published rate for ambulance services as established by the Centers for Medicare and Medicaid Services or according to the agency's billed charges, whichever is lower. The cost-sharing amounts required from the covered individual must not exceed those applicable if the services were provided by a participating agency. Insurers are prohibited from sending payment to the covered individual and must provide written notice for any claim denials, detailing the reasons or indicating if further information is needed. Notably, these provisions do not apply to insurers with contracts related to Medicaid or CHIP.

Statutes affected:
Introduced Version: 33-15-24, 33-16-20, 33-24-46, 33-25-23, 33-25A-37
Committee Substitute: 33-15-24, 33-16-20, 33-24-46, 33-25-23, 33-25A-37