The bill amends the Code of West Virginia by adding five new sections that address out-of-network ambulance services, specifically prohibiting surprise billing by non-participating emergency medical services agencies. Effective from January 1, 2027, the bill mandates that payment by insurers for covered ground ambulance services provided to a covered enrollee will be considered payment in full, excluding any required copayments, coinsurance, deductibles, and other cost-sharing amounts. Insurers are required to pay non-participating emergency medical services agencies at a rate of 200% of the current published rate established by the Centers for Medicare and Medicaid Services or according to the agency's billed charges, whichever is less.

Additionally, the bill outlines specific procedures for insurers regarding the payment and denial of claims for ground ambulance services. Insurers must remit payment directly to the non-participating agency within 30 days of receiving a clean claim and cannot send payment to the covered individual. If a claim is denied, insurers are required to provide written notice detailing the reasons for denial or requesting additional information. The bill also specifies that the copayment and other cost-sharing amounts for non-participating services cannot exceed those for participating services. 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
Enrolled Version: 33-15-24, 33-16-20, 33-24-46, 33-25-23, 33-25A-37