Current through Reg. 49, No. 38; September 20, 2024
(a) Texas Health
and Safety Code §
314A.102,
requires the Texas Health and Human Services Commission (HHSC) to conduct rate
reviews for certain hospitals operating under a Certificate of Public Advantage
(COPA).
(b) A hospital operating
under a COPA pursuant to Texas Health and Safety Code §
314A.056 may
not change rates for hospital services without prior approval from
HHSC.
(c) At least 90 days before
the implementation of any proposed change in rates for inpatient or outpatient
hospital services and, if applicable, at least 60 days before the execution of
a reimbursement agreement with a third-party payor, a hospital operating under
a COPA must submit to HHSC:
(1) a completed
rate review application as provided by HHSC;
(2) any proposed change in rates for services
that meet the definition in 25 TAC §
133.2 of "inpatient services" or
"outpatient services;"
(3) a market
analysis of current rates using geographical area;
(4) a capital expenditures requirement
beginning with the requested implementation date;
(5) if applicable, any change in
reimbursement rates under a reimbursement agreement with a third-party
payor;
(6) for an agreement with a
third-party payor, other than an agreement described by paragraph (7) of this
subsection, or in which rates are set under the Medicare or Medicaid program,
information showing:
(A) that the hospital and
the third-party payor have agreed to the proposed rates;
(B) whether the proposed rates are less than
the corresponding amounts in the producer price index published by the Bureau
of Labor Statistics of the United States Department of Labor relating to the
hospital services for which the rates are proposed, or a comparable price index
chosen by HHSC if the producer price index described by this paragraph is
abolished; and
(C) if the proposed
rates are above the corresponding amounts in the producer price index, as
described by subparagraph (B) of this paragraph, a justification for proposing
rates above the corresponding amounts in the producer price index;
(7) to the extent allowed by
federal law, for an agreement with a managed care organization that provides or
arranges for the provision of health care services under the Medicare or
Medicaid program, information showing:
(A)
whether the proposed rates are different from rates under an agreement that was
in effect before the date the applicable merger agreement took
effect;
(B) whether the proposed
rates are different from the rates most recently approved by HHSC for the
applicable hospital, if HHSC has previously approved rates for the applicable
hospital following the issuance of the COPA under this chapter that governs the
hospital; and
(C) if the proposed
rates exceed rates described by subparagraphs (A) or (B) of this paragraph, a
justification for proposing rates in excess of those rates; and
(8) any information concerning
costs, patient volume, acuity, payor mix, and other information requested by
HHSC.
(d) A hospital
operating under a COPA shall provide any information requested by HHSC, or its
designee, to HHSC or its designee no later than 10 business days after the
request. If the hospital operating under the COPA does not provide the
information HHSC requested within the 10-business-day time frame:
(1) HHSC may deny the request due to
insufficient time to review the information; or
(2) HHSC may require the hospital operating
under the COPA to amend the date of the proposed rate change.
(e) HHSC in its sole discretion
may designate an individual or entity contracted with HHSC to review the
provided materials and make a recommendation to HHSC.
(f) HHSC shall approve the proposed rate
change if HHSC determines that:
(1) the
proposed rate change likely benefits the public by maintaining or improving the
quality, efficiency, and accessibility of health care services offered to the
public; and
(2) the proposed rate
does not inappropriately exceed competitive rates for comparable services in
the hospital's market area.
(g) HHSC shall deny or modify the proposed
rate change to meet requirements outlined in subsection (f) of this section, if
HHSC determines that the proposed rate change does not satisfy subsection (f)
of this section.
(h) Subject to
subsection (d) of this section, HHSC will notify the hospital in writing of
HHSC's decision to approve, deny, or modify the proposed rate change not later
than the 30th day before the implementation date of the proposed
change.
