H. B. 2504


(By Delegates Compton, Amores, Thompson, Beane,
Hutchins, Faircloth and Douglas)

[Introduced March 12, 1997; referred to the
Committee on Banking and Insurance then Government Organization.]



A BILL to amend and reenact section twenty-one, article one, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended; to amend and reenact section three-i, article sixteen; to amend and reenact section seven-e, article twenty-four; to amend and reenact section eight-d, article twenty five; and to amend and reenact section eight-d, article twenty-five-a, all of said chapter thirty-three, all relating to coverage for emergency medical services by insurers, hospital, medical and dental corporations, health care corporations and health maintenance organizations; defining terms; requiring payment for certain emergency medical services; providing for the care of transferred patients and establishing billing procedures.

Be it enacted by the Legislature of West Virginia:
That section twenty-one, article one, chapter thirty-three of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended and reenacted; that section three-i, article sixteen be amended and reenacted; that section seven-e, article twenty-four be amended and reenacted; that section eight-d, article twenty-five be amended and reenacted; and that section eight-d, article twenty-five-a of said chapter thirty-three, be amended and reenacted, all to read as follows:
ARTICLE 1. DEFINITIONS.

§33-1-21. Emergency services.
Emergency services are those services provided in or by a hospital emergency facility or the private office of a dentist to evaluate and treat a medical condition manifesting itself by the sudden, and at the time, unexpected onset of symptoms that in the judgment of a prudent layperson who possesses an average knowledge of health and medicine, require immediate medical attention and that failure to provide medical attention would could result in serious impairment to bodily function, serious dysfunction to of any bodily organ or part, the continuance of pain or would could place the person's health in jeopardy.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-3i. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on and after the first day of July, one thousand nine hundred ninety-six, 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 may not be required.
(b) Emergency services are those services provided in or by a hospital emergency facility or the private office of a dentist to evaluate and treat a medical condition manifesting itself by the unexpected onset of symptoms, that in the judgment of a prudent layperson who possesses an average knowledge of health and medicine, requires immediate medical attention and, that failure to provide medical attention could result in serious impairment to bodily function, serious dysfunction of any bodily organ or part, the continuance of pain, or could place the person's health in jeopardy.
(c) Any policy issued pursuant to this article shall provide coverage for emergency services, as defined by this section, and may not deny coverage on the basis of lack of preauthorization, if:
(1) The insurer authorized, directed, referred or otherwise required or permitted the insured to use the emergency facility; or
(2) The insured requires an initial medical screening examination and any immediately necessary stabilizing treatment required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(3) Authorization for subsequent treatment is required and requested from the insurer but not received by the hospital or emergency facility within thirty minutes of the time authorization is requested.
(d) If an insurer and the hospital or emergency facility disagree on the medical necessity of specific emergency services for an insured, the insurer shall make all necessary arrangements to assume the care of the insured within a reasonable period of time after the disagreement arises and shallmay assume all responsibility for the transfer of an insured to a participating provider pursuant to all federal regulations and prudent medical practice. If the insurer fails to assume the care of the insured as provided by this section, coverage may not be denied for medically necessary emergency services provided to the insured on the basis of lack of prior authorization.
(e) Any policy issued pursuant to this article shall encourage the appropriate use of the 911 emergency number by its insured and may not in any way prohibit, discourage or penalize its insured for utilizing the emergency services.
(f) Any policy issued pursuant to this article shall provide for reimbursement to hospitals and providers for all reasonable and necessary emergency services within thirty days of receipt of any request for payment that is accompanied by all reasonable and necessary documentation required to support the claim: Provided, That in the event a claim is disputed by the insurer, the insurer shall notify the provider of the dispute within two weeks of receipt of the claim.
(g) In the event a hospital or emergency facility provides health care services to an insured that are not determined emergency services, as defined by this section, and the insurer does not provide coverage for the service, the provider may collect or attempt to collect payment directly from the insured.
ARTICLE 24. HOSPITAL, MEDICAL AND DENTAL CORPORATIONS.
§33-24-7e. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on and after the first day of July, one thousand nine hundred ninety-six, 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 may not be required.
(b) Emergency services are those services provided in or by a hospital emergency facility or the private office of a dentist to evaluate and treat a medical condition manifesting itself by the unexpected onset of symptoms, that in the judgment of a prudent layperson who possesses an average knowledge of health and medicine, requires immediate medical attention and, that failure to provide medical attention could result in serious impairment to bodily function, serious dysfunction of any bodily organ or part, the continuance of pain, or could place the person's health in jeopardy.
(c) Any policy, provision, contract, plan or agreement issued pursuant to this article shall provide coverage for emergency services, as defined by this section, and may not deny coverage on the basis of lack of preauthorization, if:
(1) The corporation authorized, directed, referred or otherwise required or permitted the subscriber or member to use the emergency facility; or
(2) The subscriber or member requires an initial medical screening examination and any immediately necessary stabilizing treatment required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(3) Authorization for subsequent treatment is required and requested from the corporation, but not received by the hospital or emergency facility within thirty minutes of the time the authorization is requested.
(d) If a corporation and the hospital or emergency facility disagree on the medical necessity of specific emergency services for a subscriber or member, the corporation shall make all necessary arrangements to assume the care of the subscriber or member within a reasonable period of time after the disagreement arises and shall assume all responsibility for the transfer of the subscriber or member to a participating provider pursuant to all federal regulations and prudent medical practice. If the corporation fails to assume the care of the subscriber or member as provided by this section, coverage may not be denied for medically necessary emergency services provided to the subscriber or member on the basis of lack of prior authorization.
(e) Any policy, provision, contract, plan or agreement issued pursuant to this article shall encourage the appropriate use of the 911 emergency number by its subscribers or members and may not in any way prohibit, discourage or penalize its subscribers or members for utilizing the emergency services.
(f) Any policy, provision, contract, plan or agreement issued pursuant to this article shall provide for reimbursement to hospitals and providers for all reasonable and necessary emergency services within thirty days of receipt of any request for payment that is accompanied by all reasonable and necessary documentation required to support the claim: Provided, That in the event a claim is disputed by the corporation, the corporation shall notify the provider of the dispute within two weeks of receipt of such claim.
(g) In the event a hospital or emergency facility provides health care services to a subscriber or member that are not emergency services, as defined by this section, and the corporation does not provide coverage for the service, the provider may collect or attempt to collect payment directly from the subscriber or member.
ARTICLE 25. HEALTH CARE CORPORATIONS.

§33-25-8d. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on and after the first day of July, one thousand nine hundred ninety-six, 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 may not be required.
(b) Emergency services are those services provided in or by a hospital emergency facility or the private office of a dentist to evaluate and treat a medical condition manifesting itself by the unexpected onset of symptoms, that in the judgment of a prudent layperson who possesses an average knowledge of health and medicine, requires immediate medical attention and, that failure to provide medical attention could result in serious impairment to bodily function, serious dysfunction of any bodily organ or part, the continuance of pain, or could place the person's health in jeopardy.
(c) Any policy, provision, contract, plan or agreement issued pursuant to this article shall provide coverage for emergency services, as defined by this section, and may not deny coverage on the basis of lack of preauthorization, if:
(1) The corporation authorized, directed, referred or otherwise required or permitted the subscriber or member to use the emergency facility; or
(2) The subscriber or member requires an initial medical screening examination and any immediately necessary stabilizing treatment required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(3) Authorization for subsequent treatment is required and requested of the corporation, but not received by the hospital or emergency facility within thirty minutes of the time the authorization is requested.
(d) If a corporation and the hospital or emergency facility disagree on the medical necessity of specific emergency services for a subscriber or member, the corporation shall make all necessary arrangements to assume the care of the subscriber or member within a reasonable period of time after the disagreement arises and shall assume all responsibility for the transfer of the subscriber or member to a participating provider pursuant to all federal regulations and prudent medical practice. If the corporation fails to assume the care of the subscriber or member as provided by this section, coverage may not be denied for medically necessary emergency services provided to the subscriber or member on the basis of lack of prior authorization.
(e) Any policy, provision, contract, plan or agreement issued pursuant to this article shall encourage the appropriate use of the 911 emergency number by its subscribers or members and may not in any way prohibit, discourage or penalize its subscribers or members for utilizing the emergency services.
(f) Any policy, provision, contract, plan or agreement issued pursuant to this article shall provide for reimbursement to hospitals and providers for all reasonable and necessary emergency services within thirty days of receipt of any request for payment that is accompanied by all reasonable and necessary documentation required to support the claim: Provided, That in the event a claim is disputed by the corporation, the corporation shall notify the provider of the dispute within two weeks of receipt of the claim.
(g) In the event a hospital or emergency facility provides health care services to a subscriber or member that are not emergency services, as defined in this section, and the corporation does not provide coverage for the service, the provider may collect or attempt to collect payment directly from the subscriber or member.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8d. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision, contract, plan or agreement to which this article applies, any entity regulated by this article shall, on and after the first day of July, one thousand nine hundred ninety-six, 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 may not be required.
(b) Emergency services are those services provided in or by a hospital emergency facility or the private office of a dentist to evaluate and treat a medical condition manifesting itself by the unexpected onset of symptoms, that in the judgment of a prudent layperson who possesses an average knowledge of health and medicine, requires immediate medical attention and, that failure to provide medical attention could result in serious impairment to bodily function, serious dysfunction of any bodily organ or part, the continuance of pain, or could place the person's health in jeopardy.
(c) Any policy, provision, contract, plan or agreement issued pursuant to this article shall provide coverage for emergency services, as defined by this section, and may not deny coverage on the basis of lack of preauthorization, if:
(1) The health maintenance organization authorized, directed, referred or otherwise required or permitted the enrollee to use the emergency facility; or
(2) The enrollee requires an initial medical screening examination and any immediately necessary stabilizing treatment required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. §1395dd; or
(3) Authorization for subsequent treatment is required and requested of the health maintenance organization, but not received by the hospital or emergency facility within thirty minutes of the time the authorization is requested.
(d) If a health maintenance organization and the hospital or emergency facility disagree on the medical necessity of specific emergency services for an enrollee, the health maintenance organization shall make all necessary arrangements to assume the care of the subscriber or member within a reasonable period of time after the disagreement arises and shall assume all responsibility for the transfer of the subscriber or member to a participating provider pursuant to all federal regulations and prudent medical practice. If the health maintenance organization fails to assume the care of the enrollee as provided by this section, coverage may not be denied for medically necessary emergency services provided to the enrollee on the basis of lack of prior authorization.
(e) Any policy, provision, contract, plan or agreement issued pursuant to this article shall encourage the appropriate use of the 911 emergency number by its enrollees and may not in any way prohibit, discourage or penalize its enrollees for utilizing the emergency services.
(f) Any policy, provision, contract, plan or agreement issued pursuant to this article shall provide for reimbursement to hospitals and providers for all reasonable and necessary emergency services within thirty days of receipt of any request for payment that is accompanied by all reasonable and necessary documentation required to support the claim: Provided, That in the event a claim is disputed by the health maintenance organization, the health maintenance organization shall notify the provider of the dispute within two weeks of receipt of the claim.
(g) In the event a hospital or emergency facility provides health care services to an enrollee that are not emergency services, as defined by this section, and the health maintenance organization does not provide coverage for the service, the provider may collect or attempt to collect payment directly from the enrollee.

NOTE: The purpose of this bill is to define emergency services in such a way that the observations of a prudent layperson are acceptable in determining an emergency and, to provide limitations of time for responses to preauthorization requests for medical insurance providers and HMOs and other corporate entities, to physicians and hospitals that treat insured persons on an emergency basis. The bill also provides for the payment of claims within thirty days that are accompanied with sufficient documentation, while, additionally providing time periods for insurance companies to dispute claims. Finally, it provides that providers may collect amounts paid on behalf of insureds that are not covered as the result of the claims not being due to emergency circumstances.

Strike-throughs indicate language that would be stricken from the present law, and underscoring indicates new language that would be added.