This bill amends the Code of West Virginia to regulate surprise billing for out-of-network ambulance services, specifically addressing nonparticipating emergency medical services agencies. It establishes that for health insurance policies issued on or after January 1, 2026, payments made by insurers for covered ground ambulance services will be considered full payment, excluding any copayments, coinsurance, deductibles, or other cost-sharing amounts required from the insured. Nonparticipating agencies are prohibited from billing the insured for any additional 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 requires them to either pay or deny claims within the same timeframe.

Additionally, 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 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 obligated to provide written notice for any denied claims, 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