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WEST virginia legislature
2024 regular session
Enrolled
Committee Substitute
for
Senate Bill 533
By Senators Deeds, Barrett, Hamilton, Hunt, Nelson, Phillips, Queen, Roberts, Swope, Takubo, Plymale, Maroney, and Woodrum
[Passed March 8, 2024; in effect 90 days from passage]
AN ACT to amend and reenact §16-4C-3 of the Code of West Virginia, 1931, as amended; to amend said code by adding thereto a new section, designated §16-4C-26; to amend said code by adding thereto a new section, designated §33-15-4x; to amend and reenact §33-15-21 of said code; to amend and reenact §33-16-3i of said code; to amend said code by adding thereto a new section, designated §33-16-3rr; to amend and reenact §33-24-7e of said code; to amend said code by adding thereto a new section, designated §33-24-7y; to amend and reenact §33-25-8d of said code; to amend said code by adding thereto a new section, designated §33-25-8v; to amend and reenact §33-25A-8d of said code; and to amend said code by adding thereto a new section, designated §33-25A-8y, all relating to emergency medical services; defining terms; providing that an emergency medical services agency may triage and transport a patient to an alternate destination in certain circumstances; mandating insurance coverage; providing that covered services include pre-hospital screening and stabilization of emergency conditions by an ambulance service; providing that air ambulance service is excluded from coverage; providing that coverage is subject to deductibles or copayment; providing that coverage be provided if the patient declines to be transported against medical advice; and providing effective date.
Be it enacted by the Legislature of West Virginia:
As used in this article, unless the context clearly requires a different meaning:
(a) "Ambulance" means any privately, publicly-owned vehicle, or aircraft which is designed, constructed, or modified; equipped or maintained; and operated for the transportation of patients, including, but not limited to, emergency medical services vehicles; rotary and fixed wing air ambulances; gsa kkk-A-1822 federal standard type I, type II, and type III vehicles; and specialized multipatient medical transport vehicles operated by an emergency medical services agency;
(b)(1) "Alternative destination" means a lower-acuity facility that provides medical services, including without limitation:
(A) A federally-qualified health center;
(B) An urgent care center;
(C) A rural health clinic;
(D) A physician office or medical clinic as selected by the patient; and
(E) A behavioral or mental health care facility including, without limitation, a crisis stabilization unit.
(2) "Alternative destination" does not include a:
(A) Critical access hospital;
(B) Dialysis center;
(C) Hospital;
(D) Private residence; or
(E) Skilled nursing facility.
(c) "Commissioner" means the Commissioner of the Bureau for Public Health;
(d) "Council" means the Emergency Medical Services Advisory Council created pursuant to this article;
(e) "Director" means the Director of the Office of Emergency Medical Services;
(f) "Emergency Medical Services" means all services set forth in Public Law 93-154 The Emergency Medical Services Systems Act of 1973 and those included in and made a part of the emergency medical services plan of the Department of Health inclusive of, but not limited to, responding to the medical needs of an individual to prevent the loss of life or aggravation of illness or injury;
(g) "Emergency medical services agency" means any agency licensed under §16-4C-6a of this code to provide emergency medical services;
(h) "Emergency medical services personnel" means any person certified by the commissioner to provide emergency medical services as set forth by legislative rule;
(i) "Emergency medical services provider" means any authority, person, corporation, partnership, or other entity, public or private, which owns or operates a licensed emergency medical services agency providing emergency medical services in this state;
(j) "Governing body" has the meanings ascribed to it as applied to a municipality in §8-1-2(b)(1) of this code;
(k) "Line officer" means the emergency medical services personnel, present at the scene of an accident, injury, or illness, who has taken the responsibility for patient care;
(l) "Medical command" means the issuing of orders by a physician from a medical facility to emergency medical services personnel for the purpose of providing appropriate patient care;
(m) "Municipality" has the meaning ascribed to it in §8-1-2(a)(1) of this code;
(n) "Patient" means any person who is a recipient of the services provided by emergency medical services;
(o) A rural health clinic means an outpatient care facility that provides rural health services, such as primary care and routine laboratory services, to rural and often underserved communities;
(p) "Service reciprocity" means the provision of emergency medical services to citizens of this state by emergency medical services personnel certified to render those services by a neighboring state;
(q) "Small emergency medical services provider" means any emergency medical services provider which is made up of less than 20 emergency medical services personnel; and
(r) "Specialized multipatient medical transport" means a type of ambulance transport provided for patients with medical needs greater than those of the average population, which may require the presence of a trained emergency medical technician during the transport of the patient: Provided, That the requirement of "greater medical need" may not prohibit the transportation of a patient whose need is preventive in nature.
(a) An emergency medical services agency may triage and transport a patient to an alternative destination in this state or treat in place if the emergency medical services agency is coordinating the care of the patient through medical command or telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint. Emergency medical services agencies shall execute a memorandum of understanding with alternative treatment destinations as permitted by the protocols to transport patients.
(b) On or before October 1, 2024, the director shall establish protocols for emergency medical services agencies to triage, treat, and transport to alternative destinations.
(a) The following terms are defined:
(1) "911 call" means a communication indicating that an individual may need emergency medical services;
(2) "Alternative destination" means a lower-acuity facility that provides medical services, including without limitation:
(A) A federally-qualified health center;
(B) An urgent care center;
(C) A rural health clinic;
(D) A physician office or medical clinic as selected by the patient; and
(E) A behavioral or mental health care facility including, without limitation, a crisis stabilization unit.
"Alternative destination" does not include a:
(A) Critical access hospital;
(B) Dialysis center;
(C) Hospital;
(D) Private residence; or
(E) Skilled nursing facility;
(3) "Emergency medical services agency" means any agency licensed under §16-4C-6a of this code to provide emergency medical services: Provided, That rotary and fixed wing air ambulances are specifically excluded from the definition of an emergency medical services agency;
(4) "Medical command" means the issuing of orders by a physician from a medical facility to emergency medical services personnel for the purpose of providing appropriate patient care; and
(5) "Telehealth services" means the use of synchronous or asynchronous telecommunications technology or audio-only telephone calls by a health care practitioner to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include e-mail messages or facsimile transmissions.
(b) An insurer which issues or renews a health insurance policy on or after January 1, 2025, shall provide coverage for:
(1) An emergency medical services agency to:
(A) Treat an enrollee in place if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint;
(B) Triage or triage and transport an enrollee to an alternative destination if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
(C) An encounter between an ambulance service and enrollee that results in no transport of the enrollee if:
(i) The enrollee declines to be transported against medical advice; and
(ii) The emergency medical services agency is coordinating the care of the enrollee through telehealth services or medical command with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.
(c) The coverage under this section:
(1) Only includes emergency medical services transportation to the treatment location;
(2) Is subject to the initiation of response, triage, and treatment as a result of a 911 call that is documented in the records of the emergency medical services agency;
(3) Is subject to deductibles or copayment requirements of the policy, contract, or plan;
(4) Does not diminish or limit benefits otherwise allowable under a health benefit plan, even if the billing claims for medical or behavioral health services overlap in time that is billed by the ambulance service also providing care; and
(5) Does not include rotary or fixed wing air ambulance services.
(d) The reimbursement rate for an emergency medical services agency that triages, treats, and transports a patient to an alternative destination, or triages, treats, and does not transport a patient, if the patient declines to be transported against medical advice, if the ambulance service is coordinating the care of the enrollee through medical command or telemedicine with a physician for a medical-based complaint, or with a behavioral health specialist for a behavioral-based complaint under this section, shall be reimbursed at the same rate as if the patient were transported to an emergency room of a facility provider.
From July 1, 1998:
(a) Every insurer shall provide coverage for emergency medical services, including prehospital services, to the extent necessary to screen and to stabilize an emergency medical condition. The insurer shall not require prior authorization of the screening services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Prior authorization of coverage shall not be required for stabilization if an emergency medical condition exists. Payment of claims for emergency services shall be based on the retrospective review of the presenting history and symptoms of the covered person.
(b) The coverage for prehospital screening and stabilization of an emergency medical condition shall include 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. The insurer shall pay claims for prehospital screening and stabilization of emergency condition by ambulance service if the insured is transported to an emergency room of a facility provider or if the patient declines to be transported against medical advice. The coverage under this section is subject to deductibles or copayment requirements of the policy, contract, or plan.
(c) An insurer that has given prior authorization for emergency services shall cover the services and shall not retract the authorization after the services have been provided unless the authorization was based on a material misrepresentation about the covered person's health condition made by the referring provider, the provider of the emergency services, or the covered person.
(d) Coverage of emergency services shall be subject to coinsurance, copayments, and deductibles applicable under the health benefit plan.
(e) The emergency department and the insurer shall make a good faith effort to communicate with each other in a timely fashion to expedite post evaluation or post stabilization services in order to avoid material deterioration of the covered person's condition.
(f) As used in this section:
(1) "Emergency medical services" means those services required to screen for or treat an emergency medical condition until the condition is stabilized, including prehospital care;
(2) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether an emergency medical condition exists for which emergency treatment should be sought;
(3) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the person could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part;
(4) "Stabilize" means with respect to an emergency medical condition, to provide medical treatment of the condition necessary to assure, with reasonable medical probability, that no medical deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or otherwise delay the transportation required for a higher level of care than that possible at the treating facility;
(5) "Medical screening examination" means an appropriate examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists; and
(6) "Emergency medical condition" means a condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child, serious impairment to bodily functions, or serious dysfunction of any bodily part or organ.
(a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for emergency services. A policy, provision, contract, plan, or agreement may apply to emergency services the same deductibles, coinsurance, and other limitations as apply to other covered services: Provided, that preauthorization or precertification shall not be required.
(b) From July 1, 1998, the following provisions apply:
(1) Every insurer shall provide coverage for emergency medical services, including prehospital services, to the extent necessary to screen and to stabilize an emergency medical condition. The insurer shall not require prior authorization of the screening services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Prior authorization of coverage shall not be required for stabilization if an emergency medical condition exists. Payment of claims for emergency services shall be based on the retrospective review of the presenting history and symptoms of the covered person.
(2) The coverage for prehospital screening and stabilization of an emergency medical condition shall include 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. The insurer shall pay claims for prehospital screening and stabilization of emergency condition by ambulance service if the insured is transported to an emergency room of a facility provider or if the patient declines to be transported against medical advice. The coverage under this section is subject to deductibles or copayment requirements of the policy, contract, or plan.
(3) An insurer that has given prior authorization for emergency services shall cover the services and shall not retract the authorization after the services have been provided unless the authorization was based on a material misrepresentation about the covered person's health condition made by the referring provider, the provider of the emergency services, or the covered person.
(4) Coverage of emergency services shall be subject to coinsurance, copayments, and deductibles applicable under the health benefit plan.
(5) The emergency department and the insurer shall make a good faith effort to communicate with each other in a timely fashion to expedite post evaluation or post stabilization services in order to avoid material deterioration of the covered person's condition.
(6) As used in this section:
(A) "Emergency medical services" means those services required to screen for or treat an emergency medical condition until the condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether an emergency medical condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the person could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical condition, to provide medical treatment of the condition necessary to assure, with reasonable medical probability, that no medical deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or otherwise delay the transportation required for a higher level of care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists; and
(F) "Emergency medical condition" means a condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child, serious impairment to bodily functions or serious dysfunction of any bodily part or organ.
(a) The following terms are defined:
(1) "911 call" means a communication indicating that an individual may need emergency medical services;
(2) "Alternative destination" means a lower-acuity facility that provides medical services, including without limitation:
(A) A federally-qualified health center;
(B) An urgent care center;
(C) A rural health clinic;
(D) A physician office or medical clinic as selected by the patient; and
(E) A behavioral or mental health care facility including, without limitation, a crisis stabilization unit.
"Alternative destination" does not include a:
(A) Critical access hospital;
(B) Dialysis center;
(C) Hospital;
(D) Private residence; or
(E) Skilled nursing facility;
(3) "Emergency medical services agency" means any agency licensed under §16-4C-6a of this code to provide emergency medical services: Provided, That rotary and fixed wing air ambulances are specifically excluded from the definition of an emergency medical services agency;
(4) "Medical command" means the issuing of orders by a physician from a medical facility to emergency medical services personnel for the purpose of providing appropriate patient care; and
(5) "Telehealth services" means the use of synchronous or asynchronous telecommunications technology or audio-only telephone calls by a health care practitioner to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include e-mail messages or facsimile transmissions.
(b) An insurer which issues or renews a health insurance policy on or after January 1, 2025, shall provide coverage for:
(1) An emergency medical services agency to:
(A) Treat an enrollee in place if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint;
(B) Triage or triage and transport an enrollee to an alternative destination if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
(C) An encounter between an ambulance service and enrollee that results in no transport of the enrollee if:
(i) The enrollee declines to be transported against medical advice; and
(ii) The emergency medical services agency is coordinating the care of the enrollee through telehealth services or medical command with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.
(c) The coverage under this section:
(1) Only includes emergency medical services transportation to the treatment location;
(2) Is subject to the initiation of response, triage, and treatment as a result of a 911 call that is documented in the records of the emergency medical services agency;
(3) Is subject to deductibles or copayment requirements of the policy, contract, or plan;
(4) Does not diminish or limit benefits otherwise allowable under a health benefit plan, even if the billing claims for medical or behavioral health services overlap in time that is billed by the ambulance service also providing care; and
(5) Does not include rotary or fixed wing air ambulance services.
(d) The reimbursement rate for an emergency medical services agency that triages, treats, and transports a patient to an alternative destination, or triages, treats, and does not transport a patient, if the patient declines to be transported against medical advice, if the ambulance service is coordinating the care of the enrollee through medical command or telemedicine with a physician for a medical-based complaint, or with a behavioral health specialist for a behavioral-based complaint under this section, shall be reimbursed at the same rate as if the patient were transported to an emergency room of a facility provider.
(a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for emergency services. A policy, provision, contract, plan, or agreement may apply to emergency services the same deductibles, coinsurance, and other limitations as apply to other covered services: Provided, That preauthorization or precertification shall not be required.
(b) From July 1, 1998, the following provisions apply:
(1) Every insurer shall provide coverage for emergency medical services, including prehospital services, to the extent necessary to screen and to stabilize an emergency medical condition. The insurer shall not require prior authorization of the screening services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Prior authorization of coverage shall not be required for stabilization if an emergency medical condition exists. Payment of claims for emergency services shall be based on the retrospective review of the presenting history and symptoms of the covered person.
(2) The coverage for prehospital screening and stabilization of an emergency medical condition shall include 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. The insurer shall pay claims for prehospital screening and stabilization of emergency condition by ambulance service if the insured is transported to an emergency room of a facility provider or if the patient declines to be transported against medical advice. The coverage under this section is subject to deductibles or copayment requirements of the policy, contract, or plan.
(3) An insurer that has given prior authorization for emergency services shall cover the services and shall not retract the authorization after the services have been provided unless the authorization was based on a material misrepresentation about the covered person's health condition made by the referring provider, the provider of the emergency services, or the covered person.
(4) Coverage of emergency services shall be subject to coinsurance, copayments, and deductibles applicable under the health benefit plan.
(5) The emergency department and the insurer shall make a good faith effort to communicate with each other in a timely fashion to expedite post evaluation or post stabilization services in order to avoid material deterioration of the covered person's condition.
(6) As used in this section:
(A) "Emergency medical services" means those services required to screen for or treat an emergency medical condition until the condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether an emergency medical condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the person could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical condition, to provide medical treatment of the condition necessary to assure, with reasonable medical probability, that no medical deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or otherwise delay the transportation required for a higher level of care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists; and
(F) "Emergency medical condition" means a condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child, serious impairment to bodily functions, or serious dysfunction of any bodily part or organ.
(a) The following terms are defined:
(1) "911 call" means a communication indicating that an individual may need emergency medical services;
(2) "Alternative destination" means a lower-acuity facility that provides medical services, including without limitation:
(A) A federally-qualified health center;
(B) An urgent care center;
(C) A rural health clinic;
(D) A physician office or medical clinic as selected by the patient; and
(E) A behavioral or mental health care facility including, without limitation, a crisis stabilization unit.
"Alternative destination" does not include a:
(A) Critical access hospital;
(B) Dialysis center;
(C) Hospital;
(D) Private residence; or
(E) Skilled nursing facility;
(3) "Emergency medical services agency" means any agency licensed under §16-4C-6a of this code to provide emergency medical services: Provided, That rotary and fixed wing air ambulances are specifically excluded from the definition of an emergency medical services agency;
(4) "Medical command" means the issuing of orders by a physician from a medical facility to emergency medical services personnel for the purpose of providing appropriate patient care; and
(5) "Telehealth services" means the use of synchronous or asynchronous telecommunications technology or audio-only telephone calls by a health care practitioner to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include e-mail messages or facsimile transmissions.
(b) An insurer which issues or renews a health insurance policy on or after January 1, 2025, shall provide coverage for:
(1) An emergency medical services agency to:
(A) Treat an enrollee in place if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint;
(B) Triage or triage and transport an enrollee to an alternative destination if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
(C) An encounter between an ambulance service and enrollee that results in no transport of the enrollee if:
(i) The enrollee declines to be transported against medical advice; and
(ii) The emergency medical services agency is coordinating the care of the enrollee through telehealth services or medical command with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.
(c) The coverage under this section:
(1) Only includes emergency medical services transportation to the treatment location;
(2) Is subject to the initiation of response, triage, and treatment as a result of a 911 call that is documented in the records of the emergency medical services agency;
(3) Is subject to deductibles or copayment requirements of the policy, contract, or plan;
(4) Does not diminish or limit benefits otherwise allowable under a health benefit plan, even if the billing claims for medical or behavioral health services overlap in time that is billed by the ambulance service also providing care; and
(5) Does not include rotary or fixed wing air ambulance services.
(d) The reimbursement rate for an emergency medical services agency that triages, treats, and transports a patient to an alternative destination, or triages, treats, and does not transport a patient, if the patient declines to be transported against medical advice, if the ambulance service is coordinating the care of the enrollee through medical command or telemedicine with a physician for a medical-based complaint, or with a behavioral health specialist for a behavioral-based complaint under this section, shall be reimbursed at the same rate as if the patient were transported to an emergency room of a facility provider.
(a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for emergency services. A policy, provision, contract, plan, or agreement may apply to emergency services the same deductibles, coinsurance, and other limitations as apply to other covered services: Provided, That preauthorization or precertification shall not be required.
(b) From July 1, 1998, the following provisions apply:
(1) Every insurer shall provide coverage for emergency medical services, including prehospital services, to the extent necessary to screen and to stabilize an emergency medical condition. The insurer shall not require prior authorization of the screening services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Prior authorization of coverage shall not be required for stabilization if an emergency medical condition exists. Payment of claims for emergency services shall be based on the retrospective review of the presenting history and symptoms of the covered person.
(2) The coverage for prehospital screening and stabilization of an emergency medical condition shall include 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. The insurer shall pay claims for prehospital screening and stabilization of emergency condition by ambulance service if the insured is transported to an emergency room of a facility provider or if the patient declines to be transported against medical advice. The coverage under this section is subject to deductibles or copayment requirements of the policy, contract, or plan.
(3) An insurer that has given prior authorization for emergency services shall cover the services and shall not retract the authorization after the services have been provided unless the authorization was based on a material misrepresentation about the covered person's health condition made by the referring provider, the provider of the emergency services, or the covered person.
(4) Coverage of emergency services shall be subject to coinsurance, copayments, and deductibles applicable under the health benefit plan.
(5) The emergency department and the insurer shall make a good faith effort to communicate with each other in a timely fashion to expedite post evaluation or post stabilization services in order to avoid material deterioration of the covered person's condition.
(6) As used in this section:
(A) "Emergency medical services" means those services required to screen for or treat an emergency medical condition until the condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether an emergency medical condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the person could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical condition, to provide medical treatment of the condition necessary to assure, with reasonable medical probability, that no medical deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or otherwise delay the transportation required for a higher level of care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists; and
(F) "Emergency medical condition" means a condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child, serious impairment to bodily functions or serious dysfunction of any bodily part or organ.
(a) The following terms are defined:
(1) "911 call" means a communication indicating that an individual may need emergency medical services;
(2) "Alternative destination" means a lower-acuity facility that provides medical services, including without limitation:
(A) A federally-qualified health center;
(B) An urgent care center;
(C) A rural health clinic;
(D) A physician office or medical clinic as selected by the patient; and
(E) A behavioral or mental health care facility including, without limitation, a crisis stabilization unit.
"Alternative destination" does not include a:
(A) Critical access hospital;
(B) Dialysis center;
(C) Hospital;
(D) Private residence; or
(E) Skilled nursing facility;
(3) "Emergency medical services agency" means any agency licensed under §16-4C-6a of this code to provide emergency medical services: Provided, That rotary and fixed wing air ambulances are specifically excluded from the definition of an emergency medical services agency;
(4) "Medical command" means the issuing of orders by a physician from a medical facility to emergency medical services personnel for the purpose of providing appropriate patient care; and
(5) "Telehealth services" means the use of synchronous or asynchronous telecommunications technology or audio-only telephone calls by a health care practitioner to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include e-mail messages or facsimile transmissions.
(b) An insurer which issues or renews a health insurance policy on or after January 1, 2025, shall provide coverage for:
(1) An emergency medical services agency to:
(A) Treat an enrollee in place if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint;
(B) Triage or triage and transport an enrollee to an alternative destination if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
(C) An encounter between an ambulance service and enrollee that results in no transport of the enrollee if:
(i) The enrollee declines to be transported against medical advice; and
(ii) The emergency medical services agency is coordinating the care of the enrollee through telehealth services or medical command with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.
(c) The coverage under this section:
(1) Only includes emergency medical services transportation to the treatment location;
(2) Is subject to the initiation of response, triage, and treatment as a result of a 911 call that is documented in the records of the emergency medical services agency;
(3) Is subject to deductibles or copayment requirements of the policy, contract, or plan;
(4) Does not diminish or limit benefits otherwise allowable under a health benefit plan, even if the billing claims for medical or behavioral health services overlap in time that is billed by the ambulance service also providing care; and
(5) Does not include rotary or fixed wing air ambulance services.
(d) The reimbursement rate for an emergency medical services agency that triages, treats, and transports a patient to an alternative destination, or triages, treats, and does not transport a patient, if the patient declines to be transported against medical advice, if the ambulance service is coordinating the care of the enrollee through medical command or telemedicine with a physician for a medical-based complaint, or with a behavioral health specialist for a behavioral-based complaint under this section, shall be reimbursed at the same rate as if the patient were transported to an emergency room of a facility provider.
(a) Notwithstanding any provision of any policy, provision, contract, plan, or agreement to which this article applies, any entity regulated by this article shall provide as benefits to all subscribers and members coverage for emergency services. A policy, provision, contract, plan, or agreement may apply to emergency services the same deductibles, coinsurance, and other limitations as apply to other covered services: Provided, That preauthorization or precertification shall not be required.
(b) From July 1, 1998, the following provisions apply:
(1) Every insurer shall provide coverage for emergency medical services, including prehospital services, to the extent necessary to screen and to stabilize an emergency medical condition. The insurer shall not require prior authorization of the screening services if a prudent layperson acting reasonably would have believed that an emergency medical condition existed. Prior authorization of coverage shall not be required for stabilization if an emergency medical condition exists. Payment of claims for emergency services shall be based on the retrospective review of the presenting history and symptoms of the covered person.
(2) The coverage for prehospital screening and stabilization of an emergency medical condition shall include 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. The insurer shall pay claims for prehospital screening and stabilization of emergency condition by ambulance service if the insured is transported to an emergency room of a facility provider or if the patient declines to be transported against medical advice. The coverage under this section is subject to deductibles or copayment requirements of the policy, contract, or plan.
(3) An insurer that has given prior authorization for emergency services shall cover the services and shall not retract the authorization after the services have been provided unless the authorization was based on a material misrepresentation about the covered person's health condition made by the referring provider, the provider of the emergency services, or the covered person.
(4) Coverage of emergency services shall be subject to coinsurance, copayments, and deductibles applicable under the health benefit plan.
(5) The emergency department and the insurer shall make a good faith effort to communicate with each other in a timely fashion to expedite post evaluation or post stabilization services in order to avoid material deterioration of the covered person's condition.
(6) As used in this section:
(A) "Emergency medical services" means those services required to screen for or treat an emergency medical condition until the condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether an emergency medical condition exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the person could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health, or, with respect to a pregnant woman, the health of the unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical condition, to provide medical treatment of the condition necessary to assure, with reasonable medical probability, that no medical deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility: Provided, That this provision may not be construed to prohibit, limit, or otherwise delay the transportation required for a higher level of care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists; and
(F) "Emergency medical condition" means a condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health or with respect to a pregnant woman, the health of the unborn child, serious impairment to bodily functions or serious dysfunction of any bodily part or organ.
(7) Each insurer shall provide the enrolled member with a description of procedures to be followed by the member for emergency services, including the following:
(A) The appropriate use of emergency facilities;
(B) The appropriate use of any prehospital services provided by the health maintenance organization;
(C) Any potential responsibility of the member for payment for nonemergency services rendered in an emergency facility;
(D) Any cost-sharing provisions for emergency services; and
(E) An explanation of the prudent layperson standard for emergency medical condition.
(a) The following terms are defined:
(1) "911 call" means a communication indicating that an individual may need emergency medical services;
(2) "Alternative destination" means a lower-acuity facility that provides medical services, including without limitation:
(A) A federally-qualified health center;
(B) An urgent care center;
(C) A rural health clinic;
(D) A physician office or medical clinic as selected by the patient; and
(E) A behavioral or mental health care facility including, without limitation, a crisis stabilization unit.
"Alternative destination" does not include a:
(A) Critical access hospital;
(B) Dialysis center;
(C) Hospital;
(D) Private residence; or
(E) Skilled nursing facility;
(3) "Emergency medical services agency" means any agency licensed under §16-4C-6a of this code to provide emergency medical services: Provided, That rotary and fixed wing air ambulances are specifically excluded from the definition of an emergency medical services agency;
(4) "Medical command" means the issuing of orders by a physician from a medical facility to emergency medical services personnel for the purpose of providing appropriate patient care; and
(5) "Telehealth services" means the use of synchronous or asynchronous telecommunications technology or audio-only telephone calls by a health care practitioner to provide health care services, including, but not limited to, assessment, diagnosis, consultation, treatment, and monitoring of a patient; transfer of medical data; patient and professional health-related education; public health services; and health administration. The term does not include e-mail messages or facsimile transmissions.
(b) An insurer which issues or renews a health insurance policy on or after January 1, 2025, shall provide coverage for:
(1) An emergency medical services agency to:
(A) Treat an enrollee in place if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint;
(B) Triage or triage and transport an enrollee to an alternative destination if the ambulance service is coordinating the care of the enrollee through telehealth services with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint; or
(C) An encounter between an ambulance service and enrollee that results in no transport of the enrollee if:
(i) The enrollee declines to be transported against medical advice; and
(ii) The emergency medical services agency is coordinating the care of the enrollee through telehealth services or medical command with a physician for a medical-based complaint or with a behavioral health specialist for a behavioral-based complaint.
(c) The coverage under this section:
(1) Only includes emergency medical services transportation to the treatment location;
(2) Is subject to the initiation of response, triage, and treatment as a result of a 911 call that is documented in the records of the emergency medical services agency;
(3) Is subject to deductibles or copayment requirements of the policy, contract, or plan;
(4) Does not diminish or limit benefits otherwise allowable under a health benefit plan, even if the billing claims for medical or behavioral health services overlap in time that is billed by the ambulance service also providing care; and
(5) Does not include rotary or fixed wing air ambulance services.
(d) The reimbursement rate for an emergency medical services agency that triages, treats, and transports a patient to an alternative destination, or triages, treats, and does not transport a patient, if the patient declines to be transported against medical advice, if the ambulance service is coordinating the care of the enrollee through medical command or telemedicine with a physician for a medical-based complaint, or with a behavioral health specialist for a behavioral-based complaint under this section, shall be reimbursed at the same rate as if the patient were transported to an emergency room of a facility provider.
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