WeVote
Log In

Bill

Bill

HB 4965

Relating to patient-centered treatment flexibility within the Public Employees Insurance Agency

2026 Regular Session Introduced by Laura Kimble and 2 co-sponsors

Allows PEIA enrollees with prior authorized treatment for a condition to receive a medically appropriate alternative covered treatment for the same condition without a new authoriz

Chapter 195, Acts, Regular Session, 2026
#insurance
0
WeVote Research Nonpartisan
Bill Summary · HB 4965

Summary of HB 4965 (2026) – West Virginia Public Employees Insurance Agency

Purpose and Intent

  • Establishes patient-centered treatment flexibility within the Public Employees Insurance Agency (PEIA).
  • Allows coverage for an alternative, medically appropriate treatment for the same diagnosed condition without requiring a new or additional prior authorization, under specified conditions.
  • Aims to improve access to covered care and tailor treatment to individual patient needs while maintaining cost and coverage controls.

Key Provisions and Changes

  • Definitions (§5-16-7h(a))

    • “Covered treatment”: any service, procedure, therapy, medication, or course of care covered by an agency health plan.
    • “Alternative treatment”: a different covered treatment for the same diagnosed condition that is medically appropriate and clinically indicated.
    • “Prior authorization”: approval by the agency or its administrator for coverage of a specific treatment.

  • Prior Authorization and Alternative Treatments (b)

    • If a patient has prior authorization for a covered treatment, they may receive an alternative covered treatment for the same condition without obtaining a new or additional prior authorization.
    • A patient cannot receive both the original and the alternative treatment simultaneously.

  • Coverage of Alternative Treatment (c)

    • The agency must cover the alternative treatment if: 1) It is medically appropriate for the same diagnosed condition. 2) The total allowed cost of the alternative treatment does not exceed the allowed cost of the originally authorized treatment.

  • Conditions and Documentation (d)

    • A licensed health care provider must document in the patient’s medical record that the alternative treatment is medically appropriate and targets the same diagnosed condition.
    • The agency may require documentation to verify that the allowed cost of the alternative does not exceed the original, using the agency’s pricing methods.
    • The alternative treatment cannot be used to initiate treatment for a new or unrelated diagnosis that would normally require a prior authorization.
    • The provision does not limit the agency’s authority to audit or deny claims for fraud, waste, abuse, or misrepresentation.

  • Limitations on Agency Actions (e)

    • The agency may not require a new prior authorization solely because a patient selects an alternative covered treatment that meets the section’s requirements.
    • The agency may not impose administrative hurdles that unreasonably delay access to an approved alternative treatment.

Who/What Is Affected

  • Primary Beneficiaries: PEIA enrollees (state employees and dependents) who have a diagnosed condition and a previously authorized treatment.
  • Providers: Licensed health care providers who must document medical appropriateness and the same diagnosis in the patient’s record.
  • PEIA and Plan Administrators: Responsible for ensuring coverage of cost-equivalent alternatives and applying pricing methodologies to verify cost comparisons.

Procedural and Timeline Details

  • Effective Date: The act becomes effective 90 days after passage.
  • Enactment Timeline: Passed March 12, 2026; enacted as Chapter 195, Acts, Regular Session 2026.
  • Implementation: Requires changes to PEIA’s coverage determinations, documentation requirements, and pricing methodologies to accommodate alternative treatments.

Practical Impact and Considerations

  • Potentially increases treatment flexibility and patient satisfaction by allowing medically appropriate alternatives without bureaucratic delays from additional prior authorizations.
  • Keeps cost containment in view by ensuring alternative treatments do not exceed the cost of the originally authorized treatment.
  • Relies on accurate clinical documentation and adherence to agency pricing standards.
  • Maintains safeguards against improper use, audits, and misrepresentation.

If you’d like, I can highlight specific scenarios or provide a quick comparison of examples of “alternative treatment” versus “original treatment” to illustrate how the provision would apply in real-world cases.

Compiled from official sources — confirm details with the bill’s official record.

Sign in to ask a question.