Senate Bill No. 247
(By Senators Scott, McKenzie,
Bowman and Walker)
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[Introduced March 6, 1997; referred to the Committee
on Banking and Insurance.]
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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 of said chapter; to
amend and reenact section seven-e, article twenty-four of
said chapter; to amend and reenact section eight-d, article
twenty-five of said chapter; and to amend and reenact
section eight-d, article twenty-five-a of said chapter , 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, o0n0 one thousand nine hundred thirty- one, as amended, be amended and reenacted; that section three-i,
article sixteen of said chapter be amended and reenacted; that
section seven-e, article twenty-four of said chapter be amended
and reenacted; that section eight-d, article twenty-five of said
chapter be amended and reenacted; and that section eight-d,
article twenty-five-a of said chapter, 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 shall 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 person 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.