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 65-5-6 - Procedure for Requesting a Permanent Rate Increase - Standard Application

Universal Citation: 65 WV Code of State Rules 65-5-6

Current through Register Vol. XLI, No. 13, March 29, 2024

6.1. Pre-application Conference

Prior to the filing of any rate increase application, a hospital may request a pre-application conference with the Authority's staff. The purpose of said conference is to discuss the information needed to justify the requested increase.

6.2. Standard Application

Every acute care hospital with a fiscal year which ends September 30, 1992, through the period ending August 31, 1993, must file a standard application with the Authority, as further described in this section, a minimum of forty-five (45) days prior to the beginning of its fiscal year. The purpose of this requirement is to allow the Authority to establish revenue limits for every acute care hospital under the cost-based rate review system. Only hospitals specifically and temporarily exempted from this requirement by a consent order signed by the hospital and the Authority may file a standard application at a time otherwise established by the Authority.

For subsequent fiscal years the hospital, if eligible, may file an expedited or automatic rate request. A hospital which does not file an expedited or automatic rate application and which intends to revise any of its previously approved revenue limits must file with the Authority an application containing the information described in this subsection and be in compliance with all other requirements contained in this rule and the Act.

A hospital is not required to annually file a rate application. However, if it intends to revise any of its approved revenue limits, it must do so within the time periods and in accordance with the procedure specified herein. Furthermore, a hospital shall not file more than one rate increase application per fiscal year unless the application is filed pursuant to section 7 of this rule.

The hospital must file its application with the Authority a minimum of forty-five (45) days prior to the beginning of its fiscal year.

The application must contain:

6.2.1. all of the information requested on forms provided by the Authority;

6.2.2. a written report, including the information described in W. Va. Code '16-29B-21(a)(2);

6.2.3. a proposed budget which is identical in content to the budget approved by the hospital's board. The budget must contain not only all usual information under generally accepted accounting principles for a budget, but must also contain a full and specific statement of all assumptions relied upon in preparing the budget;

6.2.4. in the event the hospital has implemented a new service within the previous twelve (12) months, a request for an adjustment in gross patient revenue due to the implementation of a new service must be supported by a certificate of need decision, if applicable. The request must also include projected utilization, a rate schedule and an operating budget detailing the revenues and direct expenses for the new service;

6.2.5. in the event the hospital intends to obtain approval of any discount contract pursuant to W. Va. Code '16-29B-20, the hospital shall also file with the Authority all of the information requested on forms provided by the Authority, which shall include an explanation of the requirements set forth in W. Va. Code '16-29B-20; the hospital shall also file a summary of the basic terms of the contract; a copy of the proposed discount contract; and, any other information required by the Authority. The Authority shall approve or deny the proposed discount contract within the one hundred eighty (180) day time period for review of rate applications set forth in subsection 6.5 of this rule. All information contained in the proposed discount contract or related thereto shall be subject to public disclosure as a public record. The provisions of this rule for consideration of discount contracts in the rate review process shall supplement the provisions for retroactive review of discount contracts for certain border hospitals pursuant to W. Va. C.S.R. '65-22-1, et seq., insofar as such provisions relate to such retroactive review of discount contracts for border hospitals previously temporarily approved under C.S.R. '65-22-1, et seq., and otherwise the provisions under C.S.R. '65-22-1, et seq., regarding temporary approval of discount contracts for certain border hospitals shall apply to the temporary approval thereof.

6.2.6. such additional information as the hospital chooses to submit or the Authority may require.

6.3. Interim Order

If a hearing is requested on the hospital's rate application by an affected party, which affected party is not the applicant or the Authority, and the request for hearing is not later withdrawn by the affected party, the hospital may request, within fifteen (15) days of receipt of the hearing request, the Authority to establish an interim rate pending the final order of the Authority.

The interim rate will be calculated by the Authority from the information contained in the pending application. The Authority will review any overage which the hospital may have at the time of the filing of the rate application and consider the amount of the overage in determining the interim rate.

The Authority will approve or deny an interim rate for the hospital within thirty (30) days after the receipt of the request for an interim rate by the hospital. The interim rate will remain in effect for six (6) months from the effective date of the interim order or until the effective date of a final order, whichever first occurs. If a final order is not entered within six (6) months from the effective date of the interim rate, the interim rate shall expire at the conclusion of the six (6) month period and the hospital shall implement the rates which were last approved by the Authority by a final order.

The Authority may rescind the interim rate during the six (6) month period if it finds that the hospital made material misrepresentations to the Authority; that the application and/or interim rate request is based upon inaccurate data; or that other good cause exists for such rescission.

If the Authority approves an interim rate increase for the hospital, the Authority may order the hospital to keep a detailed and accurate account of all amounts received by reason of the increase in rates and the purchasers and third-party payors from whom such amounts were received. The Authority may order the hospital to refund with interest to each affected purchaser and/or third-party payor any part of the increase in rates that may be held to be excessive or unreasonable. In the event a refund is not practicable, the hospital shall, under appropriate terms and conditions determined by the board, temporarily decrease its rates by an amount equal to the income realized from that portion of the increase in rates which was subsequently held to be excessive or unreasonable.

If the final order subsequently entered by the Authority establishes revenue limits for the hospital which are greater than the interim revenue limits, the hospital is prohibited from increasing its rates in excess of the limits approved by the final order.

The interim rate request is discretionary with the hospital and the interim order issued by the Authority is not a final or appealable order pursuant to W. Va. Code '16-29B-13.

6.4. Review By Authority

Upon receipt of the hospital's application, the Authority's staff shall review and analyze the application and submit to the Authority proposed revenue limits for that hospital. The Authority's staff may also require a conference with the hospital and any affected parties after the application is filed. Thereafter, the Authority shall issue a final order setting the hospital's revenue limits.

6.5. Final Order

The final order shall be sent by certified mail, return receipt requested, to the hospital and all affected parties. The hospital's community shall be notified of the final order through an announcement in the local media.

The final order on any proposed change or amendment shall not be issued more than one hundred eighty (180) days from the date the application is deemed complete by the Authority. If the Authority fails to complete its review of the application within the time period specified for the review, the rate request shall be deemed to have been approved by the Authority; unless an interim order has been issued by the Authority prior to the expiration of the one hundred eighty (180) day period.

6.6. Revised Budget and Schedule of Rates

Within twenty (20) days of receipt of the final order, the hospital must file with the Authority a revised budget, and schedule of rates, each of which shall be drafted in accordance with the revenue limits set by the final 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. All revenue limits established by the final order of the Authority must be implemented by the hospital within twenty (20) days of its receipt of the final order. The Authority may rescind the final order if the hospital fails to implement the approved rates within the twenty (20) day time period.

6.7. Notice to the Community

Contemporaneously with the filing of the application pursuant to subsection 6.2 of 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 must state the requested amount of the rate increase or decrease based upon the hospital's current actual and current approved revenue limits per nongovernmental discharge, summarize the effect of the requested relief, 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 must 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 must file with the Authority a written notice setting forth the interested party's name, address and the facts relied upon to establish his or her interest. The legal advertisement must inform the public that interested parties must file this notice within thirty (30) days of the hospital's filing of its application with the Authority or else the Authority will, except for good cause shown, reject the affected party's notice. The Authority will then send notices of all proceedings and copies of all orders to those parties deemed by the Authority to be affected parties in the matter. Proof of publication of the legal advertisement by the hospital must be submitted to the Authority within ten (10) days of the filing of its application.

Disclaimer: These regulations may not be the most recent version. West Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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