This bill amends the Code of West Virginia to address surprise billing for out-of-network ambulance services, specifically 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 must pay nonparticipating agencies either 400% of the current Medicare rate for the same service in the same geographic area or the agency's billed charges, whichever is lower.

Furthermore, the bill outlines payment procedures, requiring insurers to remit payment directly to nonparticipating emergency medical services agencies within 30 days of receiving a clean claim. Insurers must either pay or deny claims within the same timeframe, with exceptions for claims involving other payors or fraudulent submissions. If a claim is denied, insurers are obligated to provide written notice detailing the reasons for denial or indicating if further information is needed. Overall, the bill aims to protect consumers from unexpected medical bills while ensuring timely and fair compensation for emergency medical services.

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