Current through Register Vol. XLI, No. 50, December 13, 2024
Section 65-5-22 - Approval of Discount Contracts22.1. 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.c22.2.2.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.