This bill amends the Code of West Virginia to establish regulations for surprise billing related to out-of-network ground emergency medical services provided by nonparticipating providers. Effective January 1, 2026, the bill mandates that payments made by insurers to nonparticipating emergency medical services agencies will be considered full payment for the services rendered, 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 pays. The bill also sets the payment rate for insurers at either 400 percent of the current published rate for ambulance services by the Centers for Medicare and Medicaid Services or according to the agency's billed charges, whichever is lower.

The legislation further outlines specific procedures and timelines for insurers regarding claims for ground ambulance services. Insurers are required to remit payment directly to the nonparticipating agency within 30 days of receiving a clean claim and must either pay or deny the claim within the same timeframe, with certain exceptions. In the event of a claim denial, insurers must provide written notice detailing the reasons for the denial or any additional information needed. Importantly, this section does not apply to insurers with contracts related to Medicaid or CHIP, ensuring that consumers are protected from unexpected medical bills while ensuring timely payments to service providers.

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