This bill amends the Code of West Virginia to regulate surprise billing practices specifically for out-of-network ambulance services. It establishes that for health insurance policies issued on or after January 1, 2026, 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 requirements for insurers to either pay or deny claims within the same timeframe.

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 less. It also ensures that any cost-sharing amounts required from the covered individual cannot exceed what would be required if the services were provided by a participating agency. Insurers are required to provide written notice if a claim is denied, detailing the reasons for denial or indicating if further information is needed. Notably, this section does 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