West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-05 - Hospital Cost-Based Rate Review System › Section 65-5-22 - Approval of Discount Contracts

Current through Register Vol. XLI, No. 28, July 12, 2024
22.1. Pursuant to W. Va. Code '16-29D-20, no
				contract for the payment of patient car services between a purchaser or
				third-party payor and a hospital which establishes discounts to the purchaser
				or third-party payor shall take effect until it is approved by the board. To
				obtain approval by the board, a hospital must file with the Authority an
				executed copy of the proposed contract with its rate application at least
				forty-five (45) days prior to the beginning of its fiscal year and as further
				described in subsection 6.2 of this rule.
22.2. Discount contracts may be filed with
				the Authority for temporary approval subject to retroactive review outside of
				the time period described in subsection 22.1 of this rule only under the
				following conditions:
22.2.1. The hospital is
				a border hospital that meets the criteria and follows the procedure in
				legislative rule, "Temporary Approval of Discount Contracts for Border
				Hospitals," W. Va. C.S.R. '65-22-1 et seq., or
22.2.2.a. The hospital has negotiated a
				discount contract with a new entity and said negotiations could not have been
				completed and the executed contract filed with the Authority within the time
				frame specified in subsection 6.2 of this rule. For purposes of this subsection
				"new entity" is defined as a purchaser or third-party payor which has not
				previously executed a contract for the payment of patient care services with
				the hospital. Temporary approval is not available for a contract with a
				third-party payor or purchaser which has previously executed or is currently a
				party to a contract for the payment of patient care services with the
				hospital.
22.2.2.b. In order for a
				hospital to obtain temporary approval of a discount contract the hospital shall
				file a verified notice with the Authority, which shall be filed at least five
				(5) days in advance of the date upon which the proposed discount contract is to
				be considered temporarily approved and shall:
22.2.2.b.1. Identify the hospital.
22.2.2.b.2. State affirmatively that the
				discount contract is with a new entity as defined in subsection 22.2.2.a of
				this rule and identify the new entity.
22.2.2.b.3. State affirmatively that the
				hospital would be at risk to lose a significant portion of patients to other
				hospitals if the discount contract is not temporarily approved.
22.2.2.b.4. Identify the other hospital or
				hospitals.
22.2.2.b.5. State
				affirmatively the facts and circumstances which prevented the hospital and new
				entity from executing a contract and submitting it with the hospital's rate
				application.
22.2.2.b.6. State
				affirmatively that the discount shall not decrease the charges for the services
				below the actual cost to the hospital.
22.2.2.b.7. State affirmatively that the cost
				of the discount shall not be shifted to any other purchaser or third-party
				payor.
22.2.2.b.8. State
				affirmatively that the discount shall not result in a decrease in the
				hospital's proportion of medicare, medicaid, or uncompensated care
				patients.
22.2.2.b.9. State
				affirmatively that the discount is based on criteria which constitute a
				quantifiable economic benefit of the hospital.
22.2.2.b.10. Include a copy of the discount
				contract.
22.2.2.b.11. Present such
				other and further information or documents as may be requested by the
				Authority.
22.2.2.c
22.2.2.c.1. Following receipt of a verified
				notice complying with the requirements of this subsection, the Authority shall
				for the purpose of retroactive review determine within fifteen (15) days
				thereafter whether or not the verified notice is complete. If the verified
				notice is not determined complete, the Authority may request additional
				information from the hospital. Upon receipt of the additional information from
				the hospital, the Authority again has fifteen (15) days within which to
				determine whether or not the verified notice is complete.
22.2.2.c.2. Upon determining that the
				verified notice is complete, the Authority shall publish a notice of the
				determination of completeness and/or temporary approval of the discount
				contract, as may be appropriate, in the Saturday Charleston newspapers and the
				State Register and shall retroactively review the proposed discount contract
				with the hospital's next succeeding rate application in order to determine
				whether the discount contract meets all of the requirements for final approval
				set forth in W. Va. Code '16-29B-20.
22.2.2.c.3. Upon obtaining temporary approval
				of any proposed discount contract, the contract is further subject to
				retroactive review by the Authority in accordance with the criteria set forth
				in W. Va. Code '16-29B-20
				and the rate review procedures set forth in W. Va. Code '16-29B-21.
22.2.2.c.4. The effective date of any
				temporary approval is the date which is five (5) days from the date of filing
				of a verified notice meeting the requirements of subsection 22.2.2.b of this
				rule or the date the Authority determines the verified notice is complete,
				whichever first occurs.
22.2.2.c.5.
				In the event that the Authority determines that the discount contract does not
				meet all of the requirements for temporary approval set forth in this
				subsection, subsequent to a temporary approval of the contract, the Authority
				may issue an order denying and revoking the temporary approval of the discount
				contract at any time after such temporary approval. The order is effective as
				of a date established by the Authority in the order. The effective date shall
				not be less than ten (10) days from the date of the order and which effective
				date may exceed ten (10) days from the date of said order in the discretion of
				the Authority upon good cause shown for the extension.
22.2.2.c.6. In the event that the Authority
				determines during retroactive review in accordance with this section that the
				discount contract meets the standards for final approval of discount contracts
				set forth in W. Va. Code '16-29B-20, the
				Authority shall issue a final order approving the discount contract in
				accordance with the procedures for rate review set forth in W. Va. Code
				'16-29B-21.
22.2.2.c.7. In the event that the Authority
				determines that the discount contract does not meet the standards for final
				approval of discount contracts set forth in W. Va. Code '16-29B-20, the
				Authority shall issue a final order denying approval of the discount contract
				and rescinding the previous temporary approval in accordance with the
				procedures for rate review set forth in W. Va. Code '16-29B-21.