Shown verbatim: the complete text as captured from the official PDF posted by the West Virginia Legislature, fetched 2026-09-25. Page and line markers are part of the official record; nothing is edited or removed. The official bill page.
WEST VIRGINIA LEGISLATURE
2026 REGULAR SESSION
ENROLLED
Committee Substitute
for
House Bill 4965
BY DELEGATES KIMBLE, VANCE, AND MAZZOCCHI
[Passed March 12, 2026; in effect 90 days from
passage (June 10, 2026)]
Enr CS for HB 4965
1 AN ACT to amend the Code of West Virginia, 1931, as amended, by adding a new section,
2 designated §5-16-7h, relating to patient-centered treatment flexibility with the Public
3 Employees Insurance Agency.
Be it enacted by the Legislature of West Virginia:
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-7h. Patient-centered treatment flexibility.
1 (a) For purposes of this section:
2 "Covered treatment" means a service, procedure, therapy, medication, or course of care
3 covered under an agency health plan.
4 "Alternative treatment" means a different covered treatment for the same diagnosed
5 condition or illness that is medically appropriate and clinically indicated,
6 "Prior authorization" means approval issued by the agency or its administrator authorizing
7 coverage of a specific treatment.
8 (b) If a patient has received prior authorization from the agency for a covered treatment
9 for a diagnosed condition, the patient may receive an alternative covered treatment for the same
10 condition without requiring a new or additional prior authorization, subject to the requirements of
11 this section. A patient is not eligible to receive the alternative treatment and the original covered
12 treatment at the same time.
13 (c) The agency shall provide coverage for an alternative treatment selected pursuant to
14 subsection (b) of this section and may not deny coverage solely on the basis that the alternative
15 treatment was not separately prior authorized, if:
16 (1) The alternative treatment is medically appropriate for the same diagnosed condition;
17 and
18 (2) The total allowed cost to the agency for the alternative treatment does not exceed the
19 allowed cost of the originally authorized treatment.
20 (d) Coverage under this section is subject to the following conditions:
1
Enr CS for HB 4965
21 (1) A licensed health care provider shall document in the patient's medical record that the
22 alternative treatment is medically appropriate and intended to treat the same diagnosed condition
23 as the originally authorized treatment.
24 (2) The agency may require reasonable documentation to verify that the allowed cost of
25 the alternative treatment does not exceed the allowed cost of the originally authorized treatment,
26 using established agency pricing methodologies.
27 (3) Nothing in this section requires coverage of a treatment that is not otherwise a covered
28 benefit under the applicable agency health plan.
29 (4) The alternative treatment may not be used to initiate treatment for a new or unrelated
30 diagnosis for which prior authorization would otherwise be required.
31 (5) Nothing in this section limits the authority of the agency to conduct audits or deny
32 claims in cases of fraud, waste, abuse, or material misrepresentation.
33 (e) The agency may not:
34 (1) Require a new prior authorization solely because a patient elects to receive an
35 alternative covered treatment that meets the requirements of this section; or
36 (2) Impose administrative requirements that have the effect of unreasonably delaying
37 access to an alternative treatment authorized under this section.
2
Enr CS for HB 4965
The Clerk of the House of Delegates and the Clerk of the Senate hereby
certify that the foregoing bill is correctly enrolled.
...............................................................
Clerk of the House of Delegates
...............................................................
Clerk of the Senate
Originated in the House of Delegates.
In effect 90 days from passage.
...............................................................
Speaker of the House of Delegates
...............................................................
President of the Senate
__________
The within is ................................................ this the...........................................
Day of ..........................................................................................................., 2026.
.............................................................
Governor
3Every fact on this page links to its source, starting with the official bill record.