reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-7 - Outpatient Services

Current through Register Vol. XLI, No. 28, July 12, 2024
Outpatient services are not included in the benchmarking
				  analysis because of the lack of data to measure the hospitals' relative
				  performance in providing outpatient services. When this data becomes available,
				  outpatient services may be included in the benchmarking analysis. However it is
				  necessary to provide some automatic rate adjustment to the outpatient rates of
				  hospitals which elect to participate in the benchmarking process. Therefore,
				  hospitals are eligible for the same rate of increase for both the average
				  nongovernmental inpatient charge per discharge and the nongovernmental
				  outpatient charge per visit. This adjustment shall be calculated using the
				  hospital's projected actual nongovernmental outpatient charge per
				  visit.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-8 - Procedure for Requesting a Rate Increase Under the Benchmarking System

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. Time frame - A
				hospital shall file its application for a benchmark increase on forms
				prescribed by the Authority a minimum of sixty (60) days prior to the beginning
				of its fiscal year.
8.2.
				Application - The application for benchmarking shall contain, at a minimum, the
				following:
8.2.a. A budget approved by the
				hospital's board;
8.2.b. Forms
				provided by the Authority;
8.2.c. A
				copy of the legal advertisement required pursuant to section 10 of this
				rule;
8.2.d. The benchmarking
				checklist; and,
8.2.e. A copy of
				the hospital's current license.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-9 - Review by the Authority

Current through Register Vol. XLI, No. 28, July 12, 2024
Upon receipt of the hospital's application, the Authority's
				  staff shall review and analyze the application and submit to the Authority's
				  board proposed revenue limits for the hospital.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-10 - Notice to the Community

Current through Register Vol. XLI, No. 28, July 12, 2024
Contemporaneously with the filing of an application under the
				  benchmarking system pursuant to this rule, the hospital shall publish in a
				  newspaper of general circulation in the county in which the hospital is located
				  a legal advertisement setting forth the fact that the hospital is applying to
				  the Authority for a change or amendment to its schedule of rates. The legal
				  advertisement shall state the requested amount of the rate increase or decrease
				  based upon the hospital"s projected actual revenue limits per nongovernmental
				  discharge and per nongovernmental outpatient visit and further state that any
				  person desiring to inspect the application may do so at the hospital during the
				  hospital"s regular business hours and also at the offices of the Authority.
				  Also the legal advertisement shall advise the public that any person or entity
				  who claims to be an interested party in the proceedings for the changing or
				  amending of the schedule of rates shall file with the Authority a written
				  notice setting forth the party's name, address and the facts relied upon to
				  establish his or her interest. The legal advertisement shall inform the public
				  that interested parties shall file this notice within thirty (30) days of the
				  hospital"s filing of its application with the Authority or else the Authority
				  shall, except for good cause shown, reject the interested party"s notice. The
				  Authority shall then send notices of all proceedings and copies of all orders
				  to those parties determined by the Authority to be interested or affected
				  parties in the matter. The hospital shall submit proof of publication of the
				  legal advertisement to the Authority within ten (10) days of the filing of the
				  application.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-11 - Request for Hearing

Current through Register Vol. XLI, No. 28, July 12, 2024
The hospital or an affected party may request a public
				  hearing to be held on an application. A request for a public hearing must be
				  received by the Authority within thirty (30) days of the receipt by the
				  Authority of the application. The Authority, if it considers necessary, may
				  hold a public hearing on any application. The hearing shall be held no later
				  than forty-five days after receipt of the application unless good cause is
				  shown to hold the hearing at a later date.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-12 - Hearings

Current through Register Vol. XLI, No. 28, July 12, 2024
The hearing shall be conducted pursuant to the provisions of
				  W. Va. Code §
									16-29B-12.
				  The Authority may appoint a hearing examiner to conduct the hearing. The
				  Authority or the hearing examiner may schedule and require attendance at a
				  prehearing conference. The purpose of the prehearing conference shall be
				  similar to the purposes of Rule 16, West Virginia Rules of Civil Procedure. The
				  Authority shall designate affected parties at the prehearing conference unless
				  good cause is shown by the party for the Authority to designate affected party
				  status at the hearing.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-14 - Compliance

Current through Register Vol. XLI, No. 28, July 12, 2024
14.1. Overcharging
				relative to approved inpatient rates. If a hospital's average charge per
				discharge for nongovernmental inpatients exceeds the average allowed amount, it
				is subject to reductions in its requested rates for unjustified overages. The
				hospital may justify the overcharge if it can demonstrate that there has been
				an increase in its Case Mix Index (CMI) or an increase in outliers.
14.1.a. Case Mix - A hospital"s average
				charge per nongovernmental inpatient discharge is based on its costs of
				providing the services to its patients. This cost is based on the resources
				used to provide the services as measured by its own case mix index. This index
				is determined by calculating the total amount of diagnosis related groups
				(DRG's) weights and dividing them by the total discharges to derive the
				weighted average value (the case mix). Justification for an overage in the
				approved nongovernmental inpatient charges can be determined by the percentage
				increase of the case mix index from one year to the next applied to the
				hospital's previous years' allowed rates.
14.1.b. Outliers - Justification for an
				overage in the approved nongovernmental inpatient charges may also be
				determined by outliers. For the initial year:
(1) outliers for hospitals with a weighted
				average CMI greater than 1.300 or with a Level I or Level II trauma center
				designation from the Office of Health Facility Licensure and Certification are
				defined as cases which have a charge exceeding $60,000.00;
(2) outliers for hospitals with a weighted
				CMI of 1.050 to 1.300 are defined as cases which have a charge exceeding
				$50,000.00; and
(3) outliers for
				hospitals with a weighted average CMI of less than 1.050 are defined as cases
				which have a charge exceeding $26,000.00. These amounts shall be adjusted
				annually by the DRI inflation factor designated by the Authority. For
				compliance purposes, the entire charge, rather than the excess charge over the
				designated threshold, constitutes the outlier amount.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-15 - Denial of an Application

Current through Register Vol. XLI, No. 28, July 12, 2024
15.1. The
				Authority may deny any application submitted by a hospital pursuant to this
				rule if the application:
15.1.a. fails to pass
				the mathematical edit;
15.1.b. is
				materially inconsistent, inaccurate, or contains unreliable data;
15.1.c. is materially inconsistent with other
				financial data required to be filed by the hospital with the Authority pursuant
				to the Authority's legislative rule, "The Financial Disclosure Rule," 65 CSR
				§13;
15.1.d. is not submitted
				at least sixty (60) days prior to the beginning of the hospital's fiscal
				year;
15.1.e. contains material
				misrepresentations made by the hospital to the Authority;
15.1.f. is filed prior to the final approval
				of the hospital's current rates; or
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-16 - Order

Current through Register Vol. XLI, No. 28, July 12, 2024
16.1. Time Frame -
				The Authority shall issue an order setting the hospital's approved revenue
				limits no later than five (5) days prior to the beginning of the hospital's
				fiscal year except when a hearing is requested pursuant to Section 12 of this
				rule.
16.2. Certified Mail - The
				Authority shall send the order to the hospital by certified mail, return
				receipt requested.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-17 - Revised Budget and Schedule of Rates

Current through Register Vol. XLI, No. 28, July 12, 2024
Within twenty days of the effective date of the order, the
				  hospital shall file with the Authority a revised budget, if applicable, and
				  schedule of rates, each of which shall be drafted in accordance with the
				  revenue limits set by the order of the Authority. The schedule of rates shall
				  indicate the date of implementation of the rates. Thereafter, the Authority
				  shall issue a notice acknowledging receipt of the hospital"s budget and
				  schedule of rates. None of the revenue limits established by the order may be
				  implemented by the hospital prior to the beginning of the hospital"s fiscal
				  year. The Authority may rescind the order and require the hospital to repay
				  purchasers and third party payers if the hospital implements the approved rates
				  prior to the beginning of its fiscal year or prior to the effective date of the
				  order.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-18 - Reconsideration

Current through Register Vol. XLI, No. 28, July 12, 2024
If a hospital or affected party wants the Authority to
				  reconsider a final order, it shall file its request in writing and shall detail
				  the reasons for the request for reconsideration. The Authority shall consider
				  the following as reasons to grant a request for reconsideration:
a) a presentation of significant, relevant
				information not previously considered by the Authority, and a demonstration
				that with reasonable diligence the information could not have been presented
				before the Authority issued its final order;
b)a demonstration that there have been
				significant changes in factors or circumstances relied upon by the Authority in
				issuing its final order;
c)a
				demonstration that the Authority has materially failed to follow its adopted
				procedures in issuing its final order; or
d)any other basis the Authority determines
				constitutes good cause. An affected party shall file a request for
				reconsideration within thirty (30) days of the receipt of the final order by
				the requesting party. An affected party may ask for reconsideration without a
				public hearing. The Authority shall respond to the request for reconsideration
				in writing and shall state its reasons for granting or denying the request. The
				Authority is not required to hold a public hearing in every reconsideration
				proceeding. Instead, if the Authority determines that the issues do not involve
				a factual dispute or otherwise do not require the taking of further evidence
				upon the record, the Authority may issue its reconsideration decision without
				conducting a public hearing. In the event the Authority grants a
				reconsideration request but determines that a public hearing is not required,
				the Authority may enter additional evidence into the record.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-19 - Appeals

Current through Register Vol. XLI, No. 28, July 12, 2024
A final decision of the Authority shall be reviewed by the
				  state agency designated by the governor to hear appeals pursuant to W. Va. Code
				  §
									16-2D-1 et
				  seq. To be effective, the request for review must be received by the Authority
				  and the state agency designated by the governor within thirty (30) days of the
				  date upon which all parties received notice of the Authority's
				  decision.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-20 - Rates During Reconsideration Proceedings and Appeals

Current through Register Vol. XLI, No. 28, July 12, 2024
The hospital, at its discretion, may elect not to implement a
				  partial increase in its rates as approved by the Authority. If this option is
				  elected, the hospital may not recover these unimplemented rates at a later
				  date.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-21 - Compliance Reports and Orders

Current through Register Vol. XLI, No. 28, July 12, 2024
21.1. Every hospital shall file with the
				Authority a compliance report within thirty (30) days after the end of each
				quarter of the hospital"s fiscal year. The information requested for the
				compliance report shall be provided by the hospital on forms to be provided by
				the Authority. If the hospital fails to file the compliance report within
				thirty days after the end of each quarter, the Authority may deny a request for
				a rate increase.
21.2. If the
				fourth quarter compliance report indicates the hospital has exceeded its
				approved revenue limits and does not provide a justification which is accepted
				by the Authority, the Authority may order the hospital to immediately reduce
				its rates by the amount of the overage.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-22 - Reasonableness and Uniformity of Rates

Current through Register Vol. XLI, No. 28, July 12, 2024
Hospital rates shall be reasonably related to the cost of the
				  services provided and uniformly applied to all patients whether inpatient or
				  outpatient.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-23 - Discount Contracts

Current through Register Vol. XLI, No. 28, July 12, 2024
23.1.
				This section applies to all hospitals, regardless of their eligibility for
				benchmarking.
23.2. Pursuant to W.
				Va. Code §
									16-29B-20(a)(2),
				a contract which establishes a discount to a purchaser or third party payer
				cannot take effect until it is approved by the Authority. To obtain approval by
				the Authority, the hospital shall demonstrate that:
(a) the discount does not constitute an
				amount below the cost to the hospital;
(b) the cost of any discount contained in the
				contract will not be shifted to any other purchaser or third party payer;
(c) the discount will not result in
				a decrease in the hospital"s average number of Medicare, Medicaid or
				uncompensated care patients served during the previous three fiscal years; and,
(d) the discount is based upon
				criteria which constitutes a quantifiable economic benefit to the
				hospital.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-24 - Health Care Facility Financial Disclosure Act

Current through Register Vol. XLI, No. 28, July 12, 2024
The Authority shall not accept any application for a rate
				  increase or discount contract for review, unless the hospital is in compliance
				  with the Health Care Facility Financial Disclosure Act, W. Va. Code
				  '16-5F-1 et seq., and
				  the Authority's legislative rule, "Health Care Facility Financial Disclosure
				  Rule", 65 CSR §13-1. The Authority shall refuse to accept the application
				  or contract and reject it if the hospital is not in compliance with these
				  requirements.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-25 - Failure to Comply with Rules

Current through Register Vol. XLI, No. 28, July 12, 2024
A hospital or an interested or affected party which fails to
				  comply with any of the requirements of this rule is subject to sanctions
				  including the possibility of denial of all requested relief in an appropriate
				  case. Failure by the hospital or an interested or affected party to comply with
				  the time limits set forth in this rule may also, in the discretion of the
				  Authority, cause the time limits to be extended and the failing party shall be
				  considered to have waived the time periods set forth in the Act and this rule
				  or the Authority may impose another appropriate sanction.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-26 - Additional Information

Current through Register Vol. XLI, No. 28, July 12, 2024
If the Authority requires additional information from a
				  hospital or an interested or affected party, then, in the discretion of the
				  Authority, the various time limits imposed by this rule shall be tolled until
				  the requested information is received by the Authority and the Authority
				  determines the response is sufficient.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-27 - Time Periods

Current through Register Vol. XLI, No. 28, July 12, 2024
27.1. In
				each instance in this rule where a time period is stated, the period is
				intended to be a maximum period. In the event a given task is completed sooner
				than the stated period by the Authority, a hospital or an interested or
				affected party, then the next time period, if any, shall commence upon the
				actual completion date.
27.2.
				Calculation of time periods.
Whenever in this rule the date by which some action is
				  directed to be taken or accomplished would fall on a Saturday, Sunday or a
				  state holiday, then the time for taking or accomplishing the action shall be
				  extended to the next day which is not a Saturday, Sunday or a state
				  holiday.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-26 - Benchmarking And Discount Contract Rule › Section 65-26-28 - Decisions and Records Available

Current through Register Vol. XLI, No. 28, July 12, 2024
Decisions and records of the Authority may be inspected in
				  accordance with W. Va. Code §
									29B-1-3,
				  and may be copied at a charge not to exceed fifty cents per page. A handling
				  charge, not to exceed ten dollars, will be added if the Authority is requested
				  to make the copies.
TABLE 65-26A
RATE INCREASE SCALE FOR HOSPITALS UNDER THE
				  BENCHMARKING SYSTEM
POSITION RELATIVE TO BENCHMARK
						  MEDIAN
ALLOWABLE INCREASE
More than 15% below
7.5%
15% - 12.% below
7.0%
11.99% - 9% below
6.5%
8.99% - 6% below
6.0%
5.99% - 2% below
5.5%
1.99% below - 1.99% above
5.0%
2% - 5.99% above
4.5%
6% - 8.99% above
4.0%
9% - 11.99% above
3.5%
12% - 15% above
3.0%
More than 15% above
2.5%
TABLE 65-26-B
PEER GROUP RANKING AND OUTLIER THRESHOLDS FOR THE
				  INITIAL YEAR
Peer Group
Ranking
						  Criteria
Outlier Threshold
Peer Group I
CMI 1.300 or Level I or Level II
						  trauma designation
$60,000
Peer Group II
CMI of 1.050 to
						  1.300
$50,000
Peer Group III
CMI less than
						  1.050
$26,000
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-27 - Hospital Ambulatory Health Care Facilities › Section 65-27-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				legislative rule establishes the circumstances and procedures by which a
				Certificate of Need may not be required for the construction, development,
				acquisition or other establishment by a hospital of an ambulatory health care
				facility.
1.2. Authority. -- W. Va.
				Code §§
									16-2D-4(e), (f), and
				(g).
1.3. Filing Date. -- April 7, 2010.
1.4. Effective Date. -- April 7,
				2010.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-27 - Hospital Ambulatory Health Care Facilities › Section 65-27-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. As used in
				this legislative rule, all terms that are defined in section 2 of the Act have
				those same meanings which are in some cases further clarified in this rule. All
				terms not defined in the Act have the following meanings unless the context
				expressly requires otherwise.
2.1.1. Act --
				The West Virginia Health Care Authority Certificate of Need Act, W. Va. Code
				§
										16-2D-1 et
				seq.
2.1.2. Authority -- The West
				Virginia Health Care Authority which is designated to administer the
				Certificate of Need program by W. Va. Code §
										16-29B-11.
2.1.3. Verification -- A statement made under
				oath before a notary public that the information is knowingly provided and is
				true and correct.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-27 - Hospital Ambulatory Health Care Facilities › Section 65-27-3 - Exemption Criteria

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. A
				Certificate of Need may not be required for the construction, development,
				acquisition or other establishment by a hospital of an ambulatory health care
				facility under the following circumstances:
3.1.1. The ambulatory health care facility is
				located in the same county as the hospital;
3.1.2. Five or less physicians are employed
				and are licensed to practice in West Virginia pursuant to W. Va. Code §
										30-3-1 et
				seq. or § 30-14-1 et seq.;
3.1.3. The total capital expenditure does not
				exceed the expenditure minimum set forth in section two of the Act;
				and
3.1.4. The construction,
				development, acquisition or other establishment of the ambulatory health care
				facility is not opposed by an affected person after substantive public notice
				has been given by the Health Care Authority, pursuant to W. Va. Code §
										59-3-1
				et seq.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-27 - Hospital Ambulatory Health Care Facilities › Section 65-27-4 - Exemption Procedure

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Each
				applicant seeking an exemption from Certificate of Need review pursuant to this
				rule, shall file a letter with the Authority requesting that the proposal not
				be subject to Certificate of Need review. The letter shall contain the name of
				the hospital; the types of services to be provided; the number of physicians to
				be employed; the location of the proposed ambulatory health care facility; and
				the total capital expenditure associated with the proposal.
4.2. Upon receipt of the letter, the
				Authority shall provide at least thirty days' notice to the public of the
				intent of the hospital to construct, acquire or develop and ambulatory health
				care facility.
4.2.1. Within 14 business days
				after receipt of the letter, the Authority shall publish a Class II legal
				notice in a qualified newspaper of general circulation where the construction,
				acquisition, or development of the ambulatory health care facility is or will
				be geographically located. The thirty-day notice shall commence with the first
				date of publication.
4.2.2. If the
				county in which the health care facility is or will be geographically located
				contains a daily newspaper, a legal advertisement shall also be placed at least
				once in the daily newspaper.
4.2.3.
				The public notice shall include all of the information required in subsection
				4.1 of this rule.
4.2.4. The public
				notice shall also include the following statement: Any affected person may
				oppose this proposal by submitting a letter stating the reason for the
				opposition, within thirty days of the first date of publication of the public
				notice to: General Counsel, West Virginia Health Care Authority, Certificate of
				Need Program, 100 Dee Drive, Charleston, West Virginia 25311. The public notice
				shall specify the last date upon which an affected person may file a letter of
				opposition.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				legislative rule establishes the standards for the development, implementation,
				and operation of the West Virginia Health Information Network (Network) as an
				interoperable statewide network for health information exchange.
1.2. Authority. -- W. Va. Code §§
									16-29G-7
				and
				16-29B-8(a)
				(1).
1.3. Filing Date. -- April 18,
				2014.
1.4. Effective Date. -- May
				18, 2014.
1.5. Construction -- This
				legislative rule shall be liberally construed to comply with any and all
				applicable federal and state laws designed to ensure the privacy and security
				of health information.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-3 - The Health Information Exchange

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. The Network shall establish an
				interoperable statewide network for the disclosure and use of protected health
				information by and between participating organizations to improve the
				efficiency, quality, and integration of health care delivery, and to improve
				health care outcomes, all of which shall be considered to be in the best
				interests of patients pursuant to West Virginia Code § 16-29G-8. Protected
				Health Information may be disclosed and used through the health information
				exchange unless and until the patient has expressed an affirmative choice to
				opt-out.
3.2. The Network shall
				maintain the privacy and security of the health information exchange in
				accordance with all applicable federal and state laws or rules, or regulations,
				including but not limited to, HIPAA, the HIPAA privacy rules, the HIPAA
				security rules, and the HITECH Act. This privacy and security shall apply not
				only to protected health information being exchanged through the Network, but
				shall also apply to any protected health information maintained by the Network
				in its master patient index or otherwise.
3.3. There may be two types of protected
				health information transactions recognized by the Network's health information
				exchange.
3.3.a. One type may involve the
				submission of an inquiry by one participating organization seeking the
				disclosure of available protected health information on a particular patient
				from all other participating organizations, such as an inquiry for treatment
				purposes; and
3.3.b. The other type
				may involve the point-to-point disclosure of protected health information
				between two (2) participating organizations, such as in payment, clinical
				messaging, or public health reporting.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-4 - Permissible Purposes for Health Information Exchange

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. The placement of appropriate limits upon
				health information exchange shall minimize the potential for misuse or abuse of
				protected health information, thereby enhancing patient and participating
				organization confidence in the health information exchange process.
				Accordingly, the permissible purposes for which protected health information
				may be disclosed and used through the Network shall be limited by the Network.
				Permissible purposes may include treatment, emergency treatment, payment,
				health care operations, public health reporting, or any other purpose
				specifically authorized by federal and state laws or rules, or regulations, or
				approved by the Network.
4.2.
				Absent a permissible purpose, no person or participating organization shall
				seek the disclosure of protected health information through the Network's
				health information exchange.
4.3. A
				participating organization may submit an inquiry to the Network for the
				protected health information of a patient for a permissible purpose if it has a
				relationship to the patient sufficient to justify the permissible purpose. For
				example, a participating organization may submit an inquiry for treatment
				purposes when the participating organization is actually involved in the
				treatment of the patient. The Network shall implement a master patient index
				and a record locator function to identify which participating organizations
				possess protected health information responsive to an inquiry.
4.4. A participating organization may submit
				a point-to-point transaction for a permissible purpose if it has a relationship
				to the patient sufficient to justify the permissible purpose. For example, a
				participating organization treating a patient may order and receive the
				patient's laboratory tests results in the form of a clinical message from
				another participating organization or data supplier.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-5 - Patient Opt-Out

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. The
				Network shall provide a patient with a reasonable and meaningful opportunity as
				set forth in this rule to make an informed choice about whether his or her
				protected health information may be disclosed and used in the Network's health
				information exchange.
5.2. Any
				patient who does not want to consent to the disclosure and use of his or her
				protected health information in the health information exchange may elect to
				opt-out. Affirmative action by the patient is not necessary when a patient
				consents to his or her participation in the Network's health information
				exchange.
5.3. To ensure that
				patients are able to make an informed choice, participating organizations shall
				provide each patient with educational information during the first patient
				encounter after the participating organization enrolls in the Network's health
				information exchange. Where possible, patients may be provided with the
				educational information prior to the enrollment of the participating
				organization in the Network's health information exchange. This educational
				information shall be provided in writing, and if necessary, in any other format
				(on-line presentation, verbal counseling, foreign language presentation, etc.)
				designed to ensure that its contents are communicated to and understood by the
				patient.
5.4. This educational
				information shall consist of, at a minimum, a written patient notice developed
				by the Network which explains in plain language:
5.4.a. The function of the Network's health
				information exchange;
5.4.b. The
				permissible purposes for which a patient's protected health information may be
				disclosed to and used by other participating organizations through the health
				information exchange;
5.4.c. The
				types of protected health information which may be disclosed to other
				participating organizations;
5.4.d.
				The need for the patient's specific written authorization to disclose certain
				categories of sensitive health information;
5.4.e. The fact that a patient's personal
				demographic data shall be included in a master patient index maintained by the
				Network to permanently record his or her consent decision;
5.4.f. The potential benefits and risks of
				participation in the Network; and
5.4.g. The fact that a patient's
				participation in the Network is voluntary and subject to a patient's right to
				opt-out.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-6 - Patient Rights

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. The
				Network shall develop, implement, and operate its health information exchange
				in a manner that is both transparent and patient-centered;
6.1.a. All of the Network's forms and
				educational materials shall be written in plain language;
6.1.b. All of the Network's forms and
				educational materials shall be made readily accessible to patients free of
				charge either electronically, or at the request of the consumer, in paper
				format; and
6.1.c. All meetings of
				the Network's board of directors shall be conducted in compliance with the West
				Virginia Open Governmental Proceedings Act in W. Va. Code §
										6-9A-1
				et seq.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-7 - Sensitive Health Information

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. Federal and state laws impose heightened
				privacy and confidentiality requirements upon the disclosure and use of certain
				types of protected health information that may be considered particularly
				private or sensitive to a patient. The categories of sensitive health
				information may include:
7.1.a. Drug or
				alcohol abuse information;
7.1.b.
				Mental health information;
7.1.c.
				Psychotherapy notes;
7.1.d.
				Out-of-pocket goods and services;
7.1.e. Patient restricted information;
				and
7.1.f. Any other goods and
				services subject to heightened privacy and confidentiality requirements under
				federal and state laws, rules, or regulations and specifically approved by the
				Network.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-8 - Participating Organizations

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1.
				In order to request and receive a patient's protected health information
				through the Network's health information exchange; it is necessary to first
				become a participating organization. The Network may in its discretion grant
				participating organization status to any health care provider, licensed
				practitioner, public health agency, health care clearinghouse, health plan or
				other organization that establishes a contractual relationship in accordance
				with a standard participation agreement developed and approved by the Network.
				A participating organization may take the form of either a data user or a full
				service participant.
8.2. During
				the course of its development and implementation, the Network shall establish a
				plan for statewide coverage that is consistent with its available resources and
				the readiness of prospective participating organizations to connect to the
				health information exchange.
8.2.a. To
				evaluate the readiness of prospective participating organizations to connect to
				the Network, the Network shall prepare and publish interoperability guidelines
				that shall be met in order to become a participating organization.
8.2.b. The Network's interoperability
				guidelines shall be based upon national and industry health data and security
				standards regarding interoperability between and among participating
				organizations.
8.2.c. The Network's
				interoperability guidelines shall be designed reasonably to ensure that
				protected health information made available through the health information
				exchange is complete, accurate, and current.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-9 - Authorized Users

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. The
				Network and each participating organization shall designate authorized users
				based upon job roles fulfilled by individuals in their respective workforces.
				Each participating organization is responsible for establishing this role-based
				access system to limit access within an organization to those workforce members
				with a need to know.
9.2. Each
				participating organization shall designate, maintain, and certify their
				official lists of authorized users to the Network. A workforce member may be
				designated as an authorized user only if that member requires access to
				protected health information in the Network's health information exchange in
				order to perform his or her job responsibilities within the participating
				organization.
9.3. A workforce
				member who is not designated as an authorized user may not access the Network
				for any purpose.
9.4. Each
				participating organization shall provide training for its authorized users
				before they may access the health information exchange. This training program
				shall include a review of the functionality of the health information exchange,
				as well as a review of all rules, policies, and procedures promulgated by the
				Network.
9.5. Each participating
				organization is responsible for maintaining an appropriate and current list of
				its authorized users. This requires that changes in employment status as well
				as other workforce changes, including termination of authorized user status,
				shall be communicated immediately and electronically to the Network by the
				participating organization's site administrator.
9.6. The Network shall require any of its
				subcontractors and vendors that qualify as a business associate under HIPAA and
				the HITECH Act to also designate, maintain, and certify their list of
				authorized users in accordance with the role-based access concept.
9.7. A patient may seek approval for
				authorized user status if he or she registers for access to the Network's
				patient portal with a cooperating participating organization to directly access
				and view only his or her protected health information that has been contributed
				to the health information exchange by any participating organization or data
				supplier.
9.8. The Network may
				temporarily suspend or permanently revoke an individual's status as an
				authorized user of the Network for any of the following reasons;
9.8.a. Violation of this rule;
9.8.b. Violation of any federal or state law
				or rule, or regulation;
9.8.c.
				Fraudulent activity;
9.8.d.
				Prolonged inactivity on the health information exchange system; or
9.8.e. Any other good cause.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-10 - User Authentication

Current through Register Vol. XLI, No. 28, July 12, 2024
10.1.
				To optimize the privacy and security of its health information exchange, the
				Network shall ensure that an authorized user's identity is properly
				authenticated each time the exchange is accessed. The Network shall establish a
				system by which each participating organization shall implement minimum
				requirements for authentication information unique to each authorized user in
				accordance with industry standards and specifications.
10.2. The Network and the participating
				organizations shall place strict controls upon the use of authentication
				information. An authorized user to whom authentication information is assigned
				shall not share his or her authentication information with any other
				individual.
10.3. An authorized
				user shall immediately report any loss or misuse of his or her authentication
				information to the participating organization or to the Network, as applicable.
10.3.a. The Network and the participating
				organization's site may lock out the affected authorized user from accessing
				the health information exchange; and
10.3.b. This lock out shall be terminated
				only after an authorized user's identity is verified, and new authentication
				information has been approved for the authorized user in question.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-11 - Minimum Necessary

Current through Register Vol. XLI, No. 28, July 12, 2024
11.1 The
				HIPAA privacy rules apply a "minimum necessary' standard to many types of
				disclosures and uses of protected health information. This standard essentially
				means that a covered entity or business associate must make reasonable efforts
				to limit the disclosure and use of protected health information to the minimum
				necessary to accomplish the purpose of the proposed disclosure and use.
11.1.a. The minimum necessary standard is
				subject to certain exceptions:
11.1.a.1. The
				minimum necessary standard shall not apply to any disclosures and uses of
				protected health information for the permissible purposes of treatment or
				emergency treatment;
11.1.a.2. The
				minimum necessary standard shall not apply to disclosures and uses of protected
				health information pursuant to a signed authorization by the patient;
				and
11.1.a.3. The minimum necessary
				standard shall not apply to disclosures of protected health information
				pursuant to a patient's request for access to his or her own protected health
				information, such as through a Network patient portal on the Network's health
				information exchange.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-12 - Business Associates; De-Identification of protected health information

Current through Register Vol. XLI, No. 28, July 12, 2024
12.1. Under the
				HITECH Act, the Network's operation of a health information exchange qualifies
				it as a business associate of its various participating organizations, data
				suppliers, and WVDirect subscribers. Accordingly, the Network shall enter into
				a valid and binding business associate agreement with each participating
				organization, data supplier, and WVDirect subscriber. The business associate
				agreement shall comply with any and all of the requirements of HIPAA and the
				HITECH Act.
12.2. If the Network
				uses subcontractors and vendors to assist it with the development,
				implementation, and operation of the health information network, and the
				subcontractors and vendors fall within the definition of a business associate
				under HIPAA and the HITECH Act, then the Network shall enter into a valid and
				binding business associate agreement with each subcontractor or vendor. The
				business associate agreement shall comply with all of the requirements of HIPAA
				and the HITECH Act.
12.3. The HIPAA
				privacy rules identify the means by which protected health information may be
				deidentified. To be considered as deidentified, the remaining data shall not
				identify a patient, and there shall be no reasonable basis to believe that the
				information can be used to identify a patient. The Network may deidentify
				protected health information, and may disclose or use the deidentified data for
				any public health or research purpose approved by the Network board.
West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-28 - West Virginia Health Information Network Rule › Section 65-28-13 - Security Safeguards

Current through Register Vol. XLI, No. 28, July 12, 2024
13.1. The
				Network shall develop and implement appropriate administrative, physical, and
				technical safeguards designed to protect the privacy and security of any
				protected health information and personal demographic information that it
				receives, creates, discloses, or uses under its health information
				exchange.
13.2. At a minimum, these
				security safeguards shall comply with the requirements set forth in the HIPAA
				security rules codified at 45 C.F.R. §§164.306, 164.308, 164.310,
				164.312, and 164.316.
13.3. The
				Network's development and implementation of security safeguards shall remain
				consistent over time with new developments and changes. Accordingly, the intent
				of the Network is that the safeguards required by the HIPAA security rules are
				minimum safeguards. When necessary or appropriate, these safeguards may be
				amended, modified, or enhanced to keep pace with evolving technologies, new
				industry standards, and legal requirements that may become applicable in the
				future.