FISCAL NOTE
Date Requested: January 29, 2026
Time Requested: 06:23 PM |
| Agency: |
Public Employees Insurance Agency (PEIA) |
|---|
| CBD Number: |
Version: |
Bill Number: |
Resolution Number: |
| 3511 |
Introduced |
HB4965 |
|
|---|
| CBD Subject: |
Insurance |
|---|
|
FUND(S):
PEIA Basic Insurance
Sources of Revenue:
Special Fund
Legislation creates:
Increases Existing Expenses
Fiscal Note Summary
Effect this measure will have on costs and revenues of state government.
The purpose of this bill is to allow a patient who has received prior authorization from the Public Employees Insurance Agency for treatment of a medical condition to receive an alternative covered treatment for the same condition without additional prior authorization, provided the alternative treatment is medically appropriate and does not exceed the cost of the originally authorized treatment. PEIA believes this bill could potentially increase costs and cause patient care disruption.
Although the bill includes provisions to mitigate exposure to a more expensive alternative medically appropriate treatment, it allows care to proceed not receiving prior authorization for its medical appropriateness. This could result in the similarly cost alternative procedure being denied after the service is rendered due to medical inappropriateness and the member being exposed to the charges. The plan could also be exposed to additional costs as multiple procedures could be paid for a medical condition due to multiple physicians performing possibly contradictory, varying care plans. In addition to medical procedures, and arguably more critical, many prescription drugs would be removed from utilization management review that currently provide both patient safety and financial controls.
PEIA is unable to accurately estimate the number of procedures and prescription drugs that could be deemed eligible for payment under this bill. However, assuming a conservative 1% reduction in savings from medical and 3% from prescription drugs due to the removal of these medical procedures and prescription drugs from current utilization management review, PEIA will see an estimated increased cost of $3.4 million.
Fiscal Note Detail
| Effect of Proposal |
Fiscal Year |
2026
Increase/Decrease
(use"-") |
2027
Increase/Decrease
(use"-") |
Fiscal Year
(Upon Full
Implementation) |
| 1. Estmated Total Cost |
0 |
0 |
3,400,000 |
| Personal Services |
0 |
0 |
0 |
| Current Expenses |
0 |
0 |
3,400,000 |
| Repairs and Alterations |
0 |
0 |
0 |
| Assets |
0 |
0 |
0 |
| Other |
0 |
0 |
0 |
| 2. Estimated Total Revenues |
0 |
0 |
0 |
Explanation of above estimates (including long-range effect):
Please explain increases and decreases in personal services, current expenses, repairs and alterations, assets, other costs and revenues, including assumptions and data sources and delineation between start-up and ongoing costs. Please also include a long-range schedule of costs and revenues if fiscal impact is expected to vary in future years.
Memorandum
Please identify any areas of vagueness, technical defects, reasons a bill would not have a fiscal impact, and/or any special issues not captured elsewhere on this form.
Person submitting Fiscal Note: Jason Haught
Email Address: jason.a.haught@wv.gov