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WEST virginia legislature
2025 regular session
Committee Substitute
for
Senate Bill 632
By Senators Deeds and Helton
[Reported March 27, 2025, from the Committee on Health and Human Resources]
A BILL to amend the Code of West Virginia, 1931, as amended, by adding five new sections, designated §33-15-24, §33-16-20, §33-24-46, §33-25-23, and §33-25A-37, relating to surprise billing of out-of-network ambulance services; clarifying what is considered full payment to an ambulance service, what the rate of payment is, and the most an ambulance service can be paid; prohibiting billing an insured for additional costs except for fees the insurer required the insured to pay; providing procedure for payment; providing exceptions when the insurer does not have to pay within 30 days; and requiring written notices for denied claims.
Be it enacted by the Legislature of West Virginia:
For a health insurance policy issued by an insurer on or after January 1, 2026:
(1) Payment by an insurer to a nonparticipating emergency medical services agency for covered ambulance services provided under the provisions of §16-4C-1 et seq. of this code, excluding air ambulance services as defined in §16-4C-3(a) of this code, to a covered enrollee in accordance with subsection (2) of this section:
(A) Shall be considered payment in full for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay; and
(B) The nonparticipating emergency medical services agency is prohibited from billing the covered individual for any additional amount for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay.
(2) The insurer shall provide direct payment to a non-participating emergency medical services agency for covered ground ambulance services provided to a covered individual:
(A) At the rate of 400 percent of the current published rate for ambulance services as established by the Centers for Medicare and Medicaid Services under Title XVIII of the federal Social Security Act, 42 U.S.C. 1395 et seq., for the same ambulance services provided in the same geographic area; or
(B) According to the non-participating emergency medical services agency's billed charges, whichever is less.
(3) The copayment, coinsurance, deductible, and other cost-sharing amounts that an insurer requires a covered individual to pay in connection with ground ambulance services provided to the covered individual by a nonparticipating emergency medical services agency shall not exceed the copayment, coinsurance, deductible, and other cost-sharing amounts that the covered individual would be required to pay if the ambulance services had been provided to the covered individual by a participating emergency medical services agency.
(4) If an insurer receives a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall remit payment for the ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving a clean claim and shall not send payment to the covered individual.
(5) An insurer shall either pay or deny a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:
(A) Another payor or party is responsible for the claim;
(B) The insurer is coordinating benefits with another payor;
(C) The provider has already been paid for the claim;
(D) The claim was submitted fraudulently; or
(E) There was a material misrepresentation in the claim.
(6) If an insurer denies a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall provide written notice that:
(A) Acknowledges the date of the receipt of the claim; and
(B) States that the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full; or
(C) States that additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.
For a health insurance policy issued by an insurer on or after January 1, 2026:
(1) Payment by an insurer to a nonparticipating emergency medical services agency for covered ambulance services provided under the provisions of §16-4C-1 et seq. of this code, excluding air ambulance services as defined in §16-4C-3(a) of this code, to a covered enrollee in accordance with subsection (2) of this section:
(A) Shall be considered payment in full for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay; and
(B) The nonparticipating emergency medical services agency is prohibited from billing the covered individual for any additional amount for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay.
(2) The insurer shall provide direct payment to a non-participating emergency medical services agency for covered ground ambulance services provided to a covered individual:
(A) At the rate of 400 percent of the current published rate for ambulance services as established by the Centers for Medicare and Medicaid Services under Title XVIII of the federal Social Security Act, 42 U.S.C. 1395 et seq., for the same ambulance services provided in the same geographic area; or
(B) According to the nonparticipating emergency medical service agency's billed charges, whichever is less.
(3) The copayment, coinsurance, deductible, and other cost-sharing amounts that an insurer requires a covered individual to pay in connection with ground ambulance services provided to the covered individual by a nonparticipating emergency medical services agency shall not exceed the copayment, coinsurance, deductible, and other cost-sharing amounts that the covered individual would be required to pay if the ambulance services had been provided to the covered individual by a participating emergency medical services agency.
(4) If an insurer receives a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall remit payment for the ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving a clean claim and shall not send payment to the covered individual.
(5) An insurer shall either pay or deny a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:
(A) Another payor or party is responsible for the claim;
(B) The insurer is coordinating benefits with another payor;
(C) The provider has already been paid for the claim;
(D) The claim was submitted fraudulently; or
(E) There was a material misrepresentation in the claim.
(6) If an insurer denies a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall provide written notice that:
(A) Acknowledges the date of the receipt of the claim; and
(B) States that the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full; or
(C) States that additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.
For a health insurance policy issued by an insurer on or after January 1, 2026:
(1) Payment by an insurer to a nonparticipating emergency medical services agency for covered ambulance services provided under the provisions of §16-4C-1 et seq. of this code, excluding air ambulance services as defined in §16-4C-3(a) of this code, to a covered enrollee in accordance with subsection (2) of this section:
(A) Shall be considered payment in full for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay; and
(B) The nonparticipating emergency medical services agency is prohibited from billing the covered individual for any additional amount for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay.
(2) The insurer shall provide direct payment to a non-participating emergency medical services agency for covered ground ambulance services provided to a covered individual:
(A) At the rate of 400 percent of the current published rate for ambulance services as established by the Centers for Medicare and Medicaid Services under Title XVIII of the federal Social Security Act, 42 U.S.C. 1395 et seq., for the same ambulance services provided in the same geographic area; or
(B) According to the nonparticipating emergency medical service agency's billed charges, whichever is less.
(3) The copayment, coinsurance, deductible, and other cost-sharing amounts that an insurer requires a covered individual to pay in connection with ground ambulance services provided to the covered individual by a nonparticipating emergency medical services agency shall not exceed the copayment, coinsurance, deductible, and other cost-sharing amounts that the covered individual would be required to pay if the ambulance services had been provided to the covered individual by a participating emergency medical services agency.
(4) If an insurer receives a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall remit payment for the ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving a clean claim and shall not send payment to the covered individual.
(5) An insurer shall either pay or deny a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:
(A) Another payor or party is responsible for the claim;
(B) The insurer is coordinating benefits with another payor;
(C) The provider has already been paid for the claim;
(D) The claim was submitted fraudulently; or
(E) There was a material misrepresentation in the claim.
(6) If an insurer denies a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall provide written notice that:
(A) Acknowledges the date of the receipt of the claim; and
(B) States that the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full; or
(C) States that additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.
For a health insurance policy issued by an insurer on or after January 1, 2026:
(1) Payment by an insurer to a nonparticipating emergency medical services agency for covered ambulance services provided under the provisions of §16-4C-1 et seq. of this code, excluding air ambulance services as defined in §16-4C-3(a) of this code, to a covered enrollee in accordance with subsection (2) of this section:
(A) Shall be considered payment in full for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay; and
(B) The nonparticipating emergency medical services agency is prohibited from billing the covered individual for any additional amount for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay.
(2) The insurer shall provide direct payment to a non-participating emergency medical services agency for covered ground ambulance services provided to a covered individual:
(A) At the rate of 400 percent of the current published rate for ambulance services as established by the Centers for Medicare and Medicaid Services under Title XVIII of the federal Social Security Act, 42 U.S.C. 1395 et seq., for the same ambulance services provided in the same geographic area; or
(B) According to the nonparticipating emergency medical service agency's billed charges, whichever is less.
(3) The copayment, coinsurance, deductible, and other cost-sharing amounts that an insurer requires a covered individual to pay in connection with ground ambulance services provided to the covered individual by a nonparticipating emergency medical services agency shall not exceed the copayment, coinsurance, deductible, and other cost-sharing amounts that the covered individual would be required to pay if the ambulance services had been provided to the covered individual by a participating emergency medical services agency.
(4) If an insurer receives a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall remit payment for the ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving a clean claim and shall not send payment to the covered individual.
(5) An insurer shall either pay or deny a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:
(A) Another payor or party is responsible for the claim;
(B) The insurer is coordinating benefits with another payor;
(C) The provider has already been paid for the claim;
(D) The claim was submitted fraudulently; or
(E) There was a material misrepresentation in the claim.
(6) If an insurer denies a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall provide written notice that:
(A) Acknowledges the date of the receipt of the claim; and
(B) States that the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full; or
(C) States that additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.
(a) For a health insurance policy issued by an insurer on or after January 1, 2026:
(1) Payment by an insurer to a nonparticipating emergency medical services agency for covered ambulance services provided under the provisions of §16-4C-1 et seq. of this code, excluding air ambulance services as defined in §16-4C-3(a) of this code, to a covered enrollee in accordance with subsection (2) of this section:
(A) Shall be considered payment in full for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay; and
(B) The nonparticipating emergency medical services agency is prohibited from billing the covered individual for any additional amount for the ambulance services provided, except for any copayment, coinsurance, deductible, and other cost-sharing amounts that the insurer requires the covered enrollee to pay.
(2) The insurer shall provide direct payment to a non-participating emergency medical services agency for covered ground ambulance services provided to a covered individual:
(A) At the rate of 400 percent of the current published rate for ambulance services as established by the Centers for Medicare and Medicaid Services under Title XVIII of the federal Social Security Act, 42 U.S.C. 1395 et seq., for the same ambulance services provided in the same geographic area; or
(B) According to the nonparticipating emergency medical service agency's billed charges; whichever is less.
(3) The copayment, coinsurance, deductible, and other cost-sharing amounts that an insurer requires a covered individual to pay in connection with ground ambulance services provided to the covered individual by a nonparticipating emergency medical services agency shall not exceed the copayment, coinsurance, deductible, and other cost-sharing amounts that the covered individual would be required to pay if the ambulance services had been provided to the covered individual by a participating emergency medical services agency.
(4) If an insurer receives a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall remit payment for the ambulance services directly to the nonparticipating emergency medical services agency not more than 30 days after receiving a clean claim and shall not send payment to the covered individual.
(5) An insurer shall either pay or deny a clean claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency within 30 days of receipt of the claim, except in the following circumstances:
(A) Another payor or party is responsible for the claim;
(B) The insurer is coordinating benefits with another payor;
(C) The provider has already been paid for the claim;
(D) The claim was submitted fraudulently; or
(E) There was a material misrepresentation in the claim.
(6) If an insurer denies a claim for ground ambulance services provided to a covered individual by a nonparticipating emergency medical services agency, the insurer shall provide written notice that:
(A) Acknowledges the date of the receipt of the claim; and
(B) States that the insurer is declining to pay all or part of the claim and sets forth the specific reason or reasons for declining to pay the claim in full; or
(C) States that additional information is needed to determine whether all or part of the claim is payable and specifically describes the additional information that is needed.
(b) This section shall not apply to insurers that have a contract with the Bureau for Medical Services relating to Medicaid or CHIP.
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