West Virginia House Bill HB4965

West Virginia 2026 Regular Session

• Introduced: 1/29/26
• Refer: 1/29/26
• Engrossed: 3/4/26
• Refer: 3/5/26
• Report Pass: 3/10/26
• Enrolled: 3/12/26
• Passed: 3/14/26

Caption

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

Summary

HB4965 creates a new section in the West Virginia Public Employees Insurance Act to give PEIA members more flexibility when switching between covered treatments for the same diagnosed condition. If a patient has already received prior authorization for one covered treatment, the bill allows the patient to receive an alternative covered treatment for that same condition without obtaining a new or additional prior authorization, so long as the alternative is medically appropriate and clinically indicated. The bill also requires PEIA to cover the alternative treatment if its allowed cost does not exceed the cost of the originally authorized treatment. It does not expand coverage to services that are not already covered under the applicable health plan, and it does not allow the alternative treatment to be used for a new or unrelated diagnosis. Providers must document medical appropriateness, and PEIA retains authority to audit and deny claims in cases of fraud, waste, abuse, or material misrepresentation.

Impact

The bill amends West Virginia Code by adding §5-16-7h to the Public Employees Insurance Act, imposing new coverage and utilization-management rules on the Public Employees Insurance Agency. PEIA may no longer require a new prior authorization solely because a member chooses a different covered treatment for the same condition, and it may not impose administrative barriers that unreasonably delay access to that alternative treatment. The law affects PEIA members, health care providers, and the agency’s claims and prior-authorization processes, while preserving PEIA’s existing coverage limits, pricing methodologies, and anti-fraud review authority.

Sentiment

The bill appears to have broad bipartisan support and little visible opposition. It passed the House 91-0 and the Senate 31-0, indicating unanimous approval in both chambers. The lack of recorded committee transcript discussion suggests the measure was not especially controversial and was viewed as a targeted patient-access reform rather than a major policy dispute.

Contention

No significant contention is evident in the available record. The main policy balance in the bill is between patient flexibility and PEIA oversight: supporters would favor easier access to medically appropriate alternative treatments, while the agency’s safeguards preserve cost controls, documentation requirements, and fraud protections. Any potential concern would likely center on administrative burden or cost management for PEIA, but the unanimous votes suggest those concerns did not generate opposition.