Senate Bill No. 552
(By Senators Oliverio, Love, Foster, Jenkins, Bailey, White,
Hunter and Unger)
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[Introduced February 10, 2006; referred to the Committee
on Health and Human Resources; and then to the Committee on
Finance.]
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A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new section, designated §9-5-20, relating to
Medicaid coverage of nonemergency medical services; defining
terms; requiring Medicaid coverage for medical screening and
stabilization of emergency medical conditions of prudent
laypersons; and eliminating the requirement for prior
authorization for emergency medical services.
Be it enacted by the Legislature of West Virginia:
That the Code of West Virginia, 1931, as amended, be amended
by adding thereto a new section, designated §9-5-20, to read as
follows:
ARTICLE 5. MISCELLANEOUS PROVISIONS.
§9-5-20. Emergency medical services; definitions of terms; prior authorization not required.
(a) For purposes of this section, the following terms shall
apply:
(1) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including
severe pain 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 an unborn child; serious impediment to bodily functions
or serious dysfunction of any body part or organ.
(2) "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 could
result in serious jeopardy to the individual's health, or with
respect to a pregnant woman, the health of an unborn child; serious
impediment to bodily functions or serious dysfunction of any body
part or organ.
(3) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care.
(4) "Emergency services" means those services provided in or
by a hospital emergency facility, an ambulance providing related
services under the provisions of this article 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 require immediate medical attention, and that failure to
provide immediate medical attention would result in serious
impairment to bodily function, a serious dysfunction to any bodily
organ or part or would place the person's health in jeopardy.
(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.
(6) "Nonemergency services" means services provided to a
patient whose condition does not meet the definition for emergency
services or emergency medical services, all scheduled transports,
inter-facility transports or all transports to a nonacute health
care facility.
(7) "Prudent layperson" means a person who is without medical
training and 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.
(8) "Stabilize" means, with respect to a medical emergency, 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 training facility.
(b) The Department of Health and Human Resources shall provide
coverage for emergency services or emergency medical services,
including prehospital services, to the extent necessary to screen
and to stabilize an emergency medical condition. The department
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 is not required for stabilization if an emergency medical
condition exists. Payment of claims for emergency services or
emergency medical services shall be based on the retrospective
review of the presenting history and symptoms of the covered
person.
(c) In the event that the Department of Health and Human
Resources has given prior authorization for emergency services or
emergency medical services, the department 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 services or the covered
person.
(d) Coverage of emergency services or emergency medical
services shall be subject to coinsurance, copayments and
deductibles applicable under the medicaid benefit plan.
(e) The emergency department and the Department of Health and
Human Resources shall make a good faith effort to communicate with
each other in a timely fashion to expedite post-evaluation or
post-evaluation services in order to avoid material deterioration
of the covered person's condition.
NOTE: The purpose of this bill is to require medicaid
coverage of emergency medical conditions of a prudent layperson.
§9-5-20 is new; therefore, strike-throughs and underscoring
have been omitted.