Senate Bill No. 672
(By Senator Prezioso)
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[Introduced February 22, 2010; referred to the Committee on
Government Organization; and then to the Committee on Finance.]
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A BILL to repeal §16-29B-19, §16-29B-20, §16-29B-21 and §16-29B-21a
of the Code of West Virginia, 1931, as amended; to amend and
reenact §5-16-6 of said code; to amend and reenact §5F-1-3a of
said code; to amend and reenact §6-7-2a of said code; to amend
and reenact §9-4C-7 of said code; to amend and reenact
§11-27-9 and §11-27-11 of said code; to amend and reenact
§16-2D-2 and §16-2D-5 of said code; to amend and reenact
§16-5F-2, §16-5F-3, §16-5F-4, §16-5F-5 and §16-5F-6 of said
code; to amend and reenact §16-29B-3, §16-29B-5, §16-29B-6,
§16-29B-7, §16-29B-8, §16-29B-9, §16-29B-10, §16-29B-11,
§16-29B-12, §16-29B-13, §16-29B-14, §16-29B-15, §16-29B-17,
§16-29B-18, §16-29B-19a, §16-29B-23, §16-29B-24, §16-29B-25,
§16-29B-26 and §16-29B-28 of said code; to amend said code by
adding thereto a new section, designated §16-29B-5a; to amend and reenact §16-29G-2, §16-29G-4, §16-29G-5 and §16-29G-6 of
said code; to amend and reenact §16-29I-4 of said code; and to
amend and reenact §33-15B-3 of said code, all relating
generally to the Health Care Authority; repealing sections
relating generally to the Health Care Authority's authority to
set hospital rates and determine rate schedules; employment of
the members of the board of the West Virginia Health Care
Authority; setting salaries for board members; creating the
position of Executive Director of the Health Care Authority;
making the executive director the administrative head of the
Health Care Authority; setting forth the qualifications of the
executive director; adding the executive director to the
Public Employees Insurance Agency Advisory Board; clarifying
where the administrative duties of the Health Care Authority
are to be carried out; clarifying that the Board of Directors
of the Health Care Authority is the adjudicatory arm of the
Health Care Authority; requiring that the members of the board
of directors be employed on a part-time basis; setting forth
other employment requirements for the board of directors;
expanding the board of directors from three to five members;
setting forth qualifications for appointment to the board of
directors; providing that the board of directors shall report
to the executive director; establishing compensation for the board of directors; setting forth minimum hearing requirements
before the board of directors; providing for recommended
decisions by the board of directors to the executive director;
setting forth executive director procedure for review and
approval of recommended decisions of the board of directors;
providing for remand of a decision; clarifying that the
executive director has all rule-setting powers; providing for
a study by the Health Care Authority of concerns of hospitals
in border counties; requiring a comprehensive study of the
certificate of need program, including possible elimination of
certificate of need; eliminating rate review from the
authority of the Health Care Authority; making technical
corrections; and updating code references.
Be it enacted by the Legislature of West Virginia:
That §16-29B-19, §16-29B-20, §16-29B-21 and §16-29B-21a of the
Code of West Virginia, 1931, as amended, be repealed; that §5-16-6
of said code be amended and reenacted; that §5F-1-3a of said code
be amended and reenacted; that §6-7-2a of said code be amended and
reenacted; that §9-4C-7 of said code be amended and reenacted; that
§11-27-9 and §11-27-11 of said code be amended and reenacted; that
§16-2D-2 and §16-2D-5 of said code be amended and reenacted; that
§16-5F-2, §16-5F-3, §16-5F-4, §16-5F-5 and §16-5F-6 of said code be
amended and reenacted; that §16-29B-3, §16-29B-5, §16-29B-6, §16-29B-7, §16-29B-8, §16-29B-9, §16-29B-10, §16-29B-11,
§16-29B-12, §16-29B-13, §16-29B-14, §16-29B-15, §16-29B-17,
§16-29B-18, §16-29B-19a, §16-29B-23, §16-29B-24, §16-29B-25,
§16-29B-26 and §16-29B-28 of said code be amended and reenacted;
that said code be amended by adding thereto a new section,
designated §16-29B-5a; that §16-29G-2, §16-29G-4, §16-29G-5 and
§16-29G-6 of said code be amended and reenacted; that §16-29I-4 of
said code be amended and reenacted; and that §33-15B-3 of said code
be amended and reenacted, all to read as follows:
CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE GOVERNOR,
SECRETARY OF STATE AND ATTORNEY GENERAL; BOARD
OF PUBLIC WORKS; MISCELLANEOUS AGENCIES, COMMISSIONS,
OFFICES, PROGRAMS, ETC.
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-6. Creation and composition of advisory board; powers and
duties of board generally; expenses.
(a) The Public Employees Insurance Agency Advisory Board is
hereby created and established to provide advice and make
recommendations to the director concerning group hospital and
surgical insurance, group major medical insurance and group life
and accidental death insurance for all employees in the manner as
hereinafter provided. All business of the advisory board shall be
transacted in the name of West Virginia Public Employees Insurance Agency Advisory Board. The advisory board members shall receive
notice of all finance board meetings and be given the opportunity
to offer advice and recommendations to the finance board.
(b) The advisory board shall consist of fifteen members who
are citizens of the United States and residents of this state as
follows: Three members representing licensed health care
professionals, health care facilities or other types of health care
providers, one of whom shall be a physician, appointed by the
Governor, with the advice and consent of the Senate; five members
either covered by the public employees insurance plans or from
organizations representing such employees, one of whom shall
represent either retired public employees or retired educators and
one of whom shall represent county or municipal public employees,
appointed by the Governor, with the advice and consent of the
Senate, and selected so as to represent as broadly as possible all
elements of the employees covered by the plan: Provided, That such
members shall not be: (1) Employees of or contractors to any
health care facility; (2) licensed health care professionals; (3)
members of the immediate family of licensed health care
professionals; or (4) an employee of or contractor to any such
licensed health care professionals; the Insurance Commissioner or
his or her designee; one representative of the West Virginia health
care cost review authority, appointed by the Governor, with the advice and consent of the Senate; the Executive Director of the
West Virginia Health Care Authority; five members from the public
at large appointed by the Governor, with the advice and consent of
the Senate. Members of the board shall be selected to represent,
as broadly as possible, the different geographical areas within the
state. No more than ten of the fifteen members of the board shall
be of the same political party.
Of the members first appointed by the Governor to the advisory
board, one health care provider member shall be appointed for a
term of two years; one health care provider member shall be
appointed for a term of four years and one health care provider
member shall be appointed for a term of five years; the member who
is the representative of the West Virginia Health Care Cost Review
Authority shall be appointed for a term of three years; the five
members who are participants in the public employees insurance plan
shall be appointed to terms of one, two, three, four and five years
respectively; and the five members who are the public at large
shall be appointed to terms of one, two, three, four and five years
respectively. Subsequent appointed members shall be appointed to
five-year terms except for members appointed to fill vacancies who
shall serve for the remainder of the vacant term. Members of the
advisory board are eligible for reappointment upon the expiration
of their terms but may not serve more than two full five-year terms consecutively. Members' terms shall commence on September 1 of the
year of appointment and end on August 31 in the year in which the
term expires.
The advisory board shall hold a meeting at least twice each
year and shall designate the time and place of such meeting. Nine
advisory board members shall constitute a quorum at any meeting of
the advisory board. Each advisory board member shall be entitled
to one vote on each question before the advisory board. A majority
of the quorum present shall be required for a decision by the
advisory board at its meetings. The advisory board shall keep a
record of its proceedings.
The board shall elect one of its members as chairperson and
shall meet at such time and place as shall be specified by the call
of the chairperson. All meetings shall be open to the public.
Notice of each meeting shall be given in writing to each member by
the director at least three days in advance of the meeting period.
The advisory board shall be responsible for advising and
making recommendations to the director regarding the administration
and management of the Public Employees Insurance Agency as provided
for in this article. Under no circumstances, however, will the
decisions, advice or recommendations of the advisory board be
controlling or binding on the director.
The board shall pay each member the same compensation and expense reimbursement as is paid to members of the Legislature for
their interim duties as recommended by the citizens legislative
compensation commission and authorized by law for each day or
portion thereof engaged in the discharge of official duties.
CHAPTER 5F. REORGANIZATION OF THE EXECUTIVE BRANCH
OF STATE GOVERNMENT.
ARTICLE 1. GENERAL PROVISIONS.
§5F-1-3a. Executive compensation commission.
There is hereby created an executive compensation commission
composed of three members, one of whom shall be the secretary of
administration, one of whom shall be appointed by the Governor from
the names of two or more nominees submitted by the President of the
Senate, and one of whom shall be appointed by the Governor from the
names of two or more nominees submitted by the Speaker of the House
of Delegates. The names of such nominees shall be submitted to the
Governor by not later than June 1 in the year 2000, and the
appointment of such members shall be made by the Governor by not
later than July 1 in the year 2000. The members appointed by the
Governor shall have had significant business management experience
at the time of their appointment and shall serve without
compensation other than reimbursement for their reasonable expenses
necessarily incurred in the performance of their commission duties.
For the regular session of the Legislature, 2001, and every four years thereafter, the commission shall review the compensation for
cabinet secretaries and other appointed officers of this state,
including, but not limited to, the following: Commissioner,
Division of Highways; Commissioner, Bureau of Employment Programs;
Director, Division of Environmental Protection; Commissioner,
Bureau of Senior Services; Director of Tourism; Commissioner,
Division of Tax; Administrator, Division of Health; Commissioner,
Division of Corrections; Director, Division of Natural Resources;
Superintendent, State Police; Administrator, Lottery Division;
Director, Public Employees Insurance Agency; Administrator, Alcohol
Beverage Control Commission; Commissioner, Division of Motor
Vehicles; Director, Division of Personnel; Adjutant General;
chairman, Health Care Authority; members, Health Care Authority;
the Executive Director of the Health Care Authority; Director,
Division of Rehabilitation Services; Executive Director,
Educational Broadcasting Authority; Executive Secretary, Library
Commission; chairman and members of the Public Service Commission;
director of emergency services; administrator, Division of Human
Services; Executive Director, Human Rights Commission; Director,
Division of Veterans Affairs; Director, Office of Miner's Health
Safety and Training; Commissioner, Division of Banking;
Commissioner, Division of Insurance; Commissioner, Division of
Culture and History; Commissioner, Division of Labor; Director, Prosecuting Attorneys Institute; Director, Board of Risk and
Insurance Management; Commissioner, Oil and Gas Conservation
Commission; Director, Geological and Economic Survey; Executive
Director, Water Development Authority; Executive Director, Public
Defender Services; Director, State Rail Authority; chairman and
members of the Parole Board; members, Employment Security Review
Board; members, Workers' Compensation Appeal Board; Chairman,
Racing Commission; Executive Director, Women's Commission; and
Director, Hospital Finance Authority.
Following this review, but not later than the twenty-first day
of such regular session, the commission shall submit an executive
compensation report to the Legislature to include specific
recommendations for adjusting the compensation for the officers
described in this section. The recommendation may be in the form
of a bill to be introduced in each house to amend this section to
incorporate the recommended adjustments.
CHAPTER 6. GENERAL PROVISIONS RESPECTING OFFICERS.
ARTICLE 7. COMPENSATION AND ALLOWANCES.
§6-7-2a. Terms of certain appointive state officers; appointment;
qualifications; powers and salaries of such officers.
(a) Each of the following appointive state officers named in
this subsection shall be appointed by the Governor, by and with the
advice and consent of the Senate. Each of the appointive state officers serves at the will and pleasure of the Governor for the
term for which the Governor was elected and until the respective
state officers' successors have been appointed and qualified. Each
of the appointive state officers are subject to the existing
qualifications for holding each respective office and each has and
is hereby granted all of the powers and authority and shall perform
all of the functions and services heretofore vested in and
performed by virtue of existing law respecting each office.
Prior to July 1, 2006, each such named appointive state
officer shall continue to receive the annual salaries they were
receiving as of the effective date of the enactment of this section
in 2006 and thereafter, notwithstanding any other provision of this
code to the contrary, the annual salary of each named appointive
state officer shall be as follows:
Commissioner, Division of Highways, $92,500; Commissioner,
Division of Corrections, $80,000; Director, Division of Natural
Resources, $75,000; Superintendent, State Police, $85,00
0;
Commissioner, Division of Banking, $75,000; Commissioner, Division
of Culture and History, $65,000; Commissioner, Alcohol Beverage
Control Commission, $75,000; Commissioner, Division of Motor
Vehicles, $75,000; Chairman, Health Care Authority, eighty thousand
dollars; members, Health Care Authority, seventy thousand dollars;
Director, Human Rights Commission, $55,000; Commissioner, Division of Labor, $75,000; Director, Division of Veterans' Affairs,
$65,000; Chairperson, Board of Parole, $55,000; members, Board of
Parole, $50,000; members, Employment Security Review Board,
$17,000; and Commissioner, Bureau of Employment Programs, $75,000.
Secretaries of the departments shall be paid an annual salary as
follows: Health and Human Resources, $95,000; Transportation,
$95,000: Provided, That if the same person is serving as both the
Secretary of Transportation and the Commissioner of Highways, he or
she shall be paid $120,000; Revenue, $95,000; Military Affairs and
Public Safety, $95,000; Administration, $95,000; Education and the
Arts, $95,000; Commerce, $95,000; and Environmental Protection,
$95,000: Provided, however, That any increase in the salary of any
current appointive state officer named in this subsection pursuant
to the reenactment of this subsection during the regular session of
the Legislature in 2006 that exceeds $5,000 shall be paid to such
officer or his or her successor beginning on July 1, 2006, in
annual increments of $5,000 per fiscal year, up to the maximum
salary provided in this subsection: Provided further, That if the
same person is serving as both the Secretary of Transportation and
the Commissioner of Highways, then the annual increments of $5,000
per fiscal year do not apply.
(b) Each of the state officers named in this subsection shall
continue to be appointed in the manner prescribed in this code and, prior to July 1, 2006, each of the state officers named in this
subsection shall continue to receive the annual salaries he or she
was receiving as of the effective date of the enactment of this
section in 2006 and shall thereafter, notwithstanding any other
provision of this code to the contrary, be paid an annual salary as
follows:
Director, Board of Risk and Insurance Management, $80,000;
Director, Division of Rehabilitation Services, $75,000; Director,
Division of Personnel, $75,000; Executive Director, Educational
Broadcasting Authority, $75,000; Secretary, Library Commission,
$72,000; Director, Geological and Economic Survey, $75,000;
Executive Director, Prosecuting Attorneys Institute, $70,000;
Executive Director, Public Defender Services, $75,000;
Commissioner, Bureau of Senior Services, $75,000; Director, State
Rail Authority, $65,000; Executive Director, Women's Commission,
$45,000; Director, Hospital Finance Authority, $35,000; member,
Racing Commission, $12,000; Chairman, Public Service Commission,
$85,000; members, Public Service Commission, $85,000; Director,
Division of Forestry, $75,000; Director, Division of Juvenile
Services, $80,000; and Executive Director, Regional Jail and
Correctional Facility Authority, $80,000: Provided, That any
increase in the salary of any current appointive state officer
named in this subsection pursuant to the reenactment of this subsection during the regular session of the Legislature in 2006
that exceeds $5,000 shall be paid to such officer or his or her
successor beginning on July 1, 2006, in annual increments of $5,000
per fiscal year, up to the maximum salary provided in this
subsection.
(c) Each of the following appointive state officers named in
this subsection shall be appointed by the Governor, by and with the
advice and consent of the Senate. Each of the appointive state
officers serves at the will and pleasure of the Governor for the
term for which the Governor was elected and until the respective
state officers' successors have been appointed and qualified. Each
of the appointive state officers are subject to the existing
qualifications for holding each respective office and each has and
is hereby granted all of the powers and authority and shall perform
all of the functions and services heretofore vested in and
performed by virtue of existing law respecting each office.
Prior to July 1, 2006, each such named appointive state
officer shall continue to receive the annual salaries they were
receiving as of the effective date of the enactment of this section
in 2006 and thereafter, notwithstanding any other provision of this
code to the contrary, the annual salary of each named appointive
state officer shall be as follows:
Commissioner, State Tax Division, $92,500; Commissioner, Insurance Commission, $92,500; Director, Lottery Commission,
$92,500
; Director, Division of Homeland Security and Emergency
Management, $65,000; and Adjutant General, $92,500.
(d) No increase in the salary of any appointive state officer
pursuant to this section shall be paid until and unless the
appointive state officer has first filed with the State Auditor and
the Legislative Auditor a sworn statement, on a form to be
prescribed by the Attorney General, certifying that his or her
spending unit is in compliance with any general law providing for
a salary increase for his or her employees. The Attorney General
shall prepare and distribute the form to the affected spending
units.
CHAPTER 9. HUMAN SERVICES.
ARTICLE 4C. HEALTH CARE PROVIDER MEDICAID ENHANCEMENT ACT.
§9-4C-7. Powers and duties.
(a) Each board created pursuant to this article shall:
(1) Develop, recommend and review reimbursement methodology
where applicable, and develop and recommend a reasonable provider
fee schedule, in relation to its respective provider groups, so
that the schedule conforms with federal Medicaid laws and remains
within the limits of annual funding available to the single state
agency for the Medicaid program. In developing the fee schedule
the board may refer to a nationally published regional specific fee schedule, if available, as selected by the secretary in accordance
with section eight of this article. The board may consider
identified health care priorities in developing its fee schedule to
the extent permitted by applicable federal Medicaid laws, and may
recommend higher reimbursement rates for basic primary and
preventative health care services than for other services. In
identifying basic primary and preventative health care services,
the board may consider factors, including, but not limited to,
services defined and prioritized by the basic services task force
of the health care planning commission in its report issued in
December of the year 1992; and minimum benefits and coverages for
policies of insurance as set forth in section fifteen, article
fifteen, chapter thirty-three of this code and section four,
article sixteen-c of said chapter and rules of the Insurance
Commissioner promulgated thereunder. If the single state agency
approves the adjustments to the fee schedule, it shall implement
the provider fee schedule;
(2) Review its respective provider fee schedule on a quarterly
basis and recommend to the single state agency any adjustments it
considers necessary. If the single state agency approves any of
the board's recommendations, it shall immediately implement those
adjustments and shall report the same to the Joint Committee on
Government and Finance on a quarterly basis;
(3) Assist and enhance communications between participating
providers and the Department of Health and Human Resources;
(4) Meet and confer with representatives from each specialty
area within its respective provider group so that equity in
reimbursement increases or decreases may be achieved to the
greatest extent possible and when appropriate to meet and confer
with other provider boards; and
(5) Appoint a chairperson to preside over all official
transactions of the board.
(b) Each board may carry out any other powers and duties as
prescribed to it by the secretary.
(c) Nothing in this section gives any board the authority to
interfere with the discretion and judgment given to the single
state agency that administers the state's Medicaid program. If the
single state agency disapproves the recommendations or adjustments
to the fee schedule, it is expressly authorized to make any
modifications to fee schedules as are necessary to ensure that
total financial requirements of the agency for the current fiscal
year with respect to the state's Medicaid plan are met and shall
report such modifications to the Joint Committee on Government and
Finance on a quarterly basis. The purpose of each board is to
assist and enhance the role of the single state agency in carrying
out its mandate by acting as a means of communication between the
health care provider community and the agency.
(d) In addition to the duties specified in subsection (a) of
this section, the ambulance service provider Medicaid board shall
work with the health care cost review authority to develop a method for regulating rates charged by ambulance services. The health
care cost review authority shall report its findings to the
Legislature by the first day of January, one thousand nine hundred
ninety-four. The costs of the report shall be paid by the health
care cost review authority. In this capacity only, the chairperson
of the health care cost review authority shall serve as an ex
officio, nonvoting member of the board.
(e) (d) On a quarterly basis, the single state agency and the
board shall report the status of the fund, any adjustments to the
fee schedule and the fee schedule for each health care provider
identified in section two of this article to the Joint Committee on
Government and Finance.
CHAPTER 11. TAXATION.
ARTICLE 27. HEALTH CARE PROVIDER TAXES.
§11-27-9. Imposition of tax on providers of inpatient hospital
services.
(a) Imposition of tax. -- For the privilege of engaging or
continuing within this state in the business of providing inpatient
hospital services, there is hereby levied and shall be collected
from every person rendering such service an annual broad-based
health care related tax: Provided, That a hospital which meets all
the requirements of section twenty-one, article twenty-nine-b,
chapter sixteen of this code and regulations thereunder may change
or amend its schedule of rates to the extent necessary to
compensate for the tax in accordance with the following procedures:
(1) The health care cost review authority shall allow a
temporary change in a hospital's rates which may be effective
immediately upon filing and in advance of review procedures when a
hospital files a verified claim that such temporary rate changes
are in the public interest, and are necessary to prevent
insolvency, to maintain accreditation or for emergency repairs or
to relieve undue financial hardship. The verified claim shall
state the facts supporting the hospital's position, the amount of
increase in rates required to alleviate the situation and shall
summarize the overall effect of the rate increase. The claim shall
be verified by either the chairman of the hospital's governing body
or by the chief executive officer of the hospital.
(2) Following receipt of the verified claim for temporary
relief, the health care cost review authority shall review the
claim through its usual procedures and standards; however, this
power of review does not affect the hospital's ability to place the
temporary rate increase into effect immediately. The review of the
hospital's claim shall be for a permanent rate increase and the
health care cost review authority may include such other factual
information in the review as may be necessary for a permanent rate
increase review. As a result of its findings from the permanent
review, the health care cost review authority may allow the
temporary rate increase to become permanent, to deny any increase
at all, to allow a lesser increase, or to allow a greater increase.
(3) When any change affecting an increase in rates goes into effect before a final order is entered in the proceedings, for
whatever reasons, where it deems it necessary and practicable, the
health care cost review 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. At the conclusion of any
hearing, appeal or other proceeding, the health care cost review
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 health care cost
review authority, charge over and amortize by means of a temporary
decrease in rates whatever income is realized from that portion of
the increase in rates which was subsequently held to be excessive
or unreasonable.
(4) The health care cost review authority, upon a
determination that a hospital has overcharged purchasers or charged
purchasers at rates not approved by the health care cost review
authority or charged rates which were subsequently held to be
excessive or unreasonable, may prescribe rebates to purchasers and
third-party payors in effect by the aggregate total of the
overcharge.
(5) the rate adjustment provided for in this section is
limited to a single adjustment during the initial year of the imposition of the tax provided for in this section.
(b) Rate and measure of tax. -- The tax imposed in subsection
(a) of this section shall be two and one-half percent of the gross
receipts derived by the taxpayer from furnishing inpatient hospital
services in this state.
(c) Definitions. --
(1) "Gross receipts" means the amount received or receivable,
whether in cash or in kind, from patients, third-party payors and
others for inpatient hospital services furnished by the provider,
including retroactive adjustments under reimbursement agreements
with third-party payors, without any deduction for any expenses of
any kind: Provided, That accrual basis providers shall be allowed
to reduce gross receipts by their contractual allowances, to the
extent such allowances are included therein, and by bad debts, to
the extent the amount of such bad debts was previously included in
gross receipts upon which the tax imposed by this section was paid.
(2) "Contractual allowances" means the difference between
revenue (gross receipts) at established rates and amounts
realizable from third-party payors under contractual agreements.
(3) "Inpatient hospital services" means those services that
are inpatient hospital services for purposes of Section 1903(w) of
the Social Security Act.
(d) Effective date. -- The tax imposed by this section shall
apply to gross receipts received or receivable by providers after
May 31, 1993.
§11-27-11. Imposition of tax on providers of nursing facility
services, other than services of intermediate care
facilities for the mentally retarded.
(a) Imposition of tax. -- For the privilege of engaging or
continuing within this state in the business of providing nursing
facility services, other than those services of intermediate care
facilities for the mentally retarded, there is hereby levied and
shall be collected from every person rendering such service an
annual broad-based health care related tax: Provided, That
hospitals which provide nursing facility services may adjust
nursing facility rates to the extent necessary to compensate for
the tax without first obtaining approval from the Health Care
Authority: Provided, however, That the rate adjustment is limited
to a single adjustment during the initial year of the imposition of
the tax which adjustment shall be exempt from prospective review by
the Health Care Authority and, further, which is limited to an
amount not to exceed the amount of the tax which is levied against
the hospital for the provision of nursing facility services
pursuant to this section. The Health Care Authority shall
retroactively review the rate increases implemented by the
hospitals under this section during the regular rate review
process. A hospital which fails to meet the criteria established
by this section for a rate increase exempt from prospective review
shall be subject to the penalties imposed under article twenty-
nine-b, chapter sixteen of the code.
(b) Rate and measure of tax. -- The tax imposed in subsection
(a) of this section shall be five and one-half percent of the gross
receipts derived by the taxpayer from furnishing nursing facility
services in this state, other than services of intermediate care
facilities for the mentally retarded. This rate shall be increased
to five and ninety-five one hundredths percent of the gross
receipts received or receivable by providers of nursing facility
services after June 13, 2004, and shall again be decreased to five
and one-half percent of the gross receipts received or receivable
by providers of nursing services after October 31, 2007.
(c) Definitions. --
(1) "Gross receipts" means the amount received or receivable,
whether in cash or in kind, from patients, third-party payors and
others for nursing facility services furnished by the provider,
including retroactive adjustments under reimbursement agreements
with third-party payors, without any deduction for any expenses of
any kind: Provided, That accrual basis providers shall be allowed
to reduce gross receipts by their bad debts, to the extent the
amount of such bad debts was previously included in gross receipts
upon which the tax imposed by this section was paid.
(2) "Nursing facility services" means those services that are
nursing facility services for purposes of Section 1903(w) of the
Social Security Act.
(d) Effective date. -- The tax imposed by this section shall
apply to gross receipts received or receivable by providers after May 31, 1993.
CHAPTER 16. PUBLIC HEALTH.
ARTICLE 2D. CERTIFICATE OF NEED.
§16-2D-2. Definitions.
Definitions of words and terms defined in articles five-f and
twenty-nine-b of this chapter are incorporated in this section
unless this section has different definitions.
As used in this article, unless otherwise indicated by the
context:
(a) "Affected person" means:
(1) The applicant;
(2) An agency or organization representing consumers;
(3) Any individual residing within the geographic area served
or to be served by the applicant;
(4) Any individual who regularly uses the health care
facilities within that geographic area;
(5) The health care facilities which provide services similar
to the services of the facility under review and which will be
significantly affected by the proposed project;
(6) The health care facilities which, prior to receipt by the
state agency of the proposal being reviewed, have formally
indicated an intention to provide similar services in the future;
(7) Third-party payors who reimburse health care facilities
similar to those proposed for services;
(8) Any agency that establishes rates for health care facilities similar to those proposed; or
(9) Organizations representing health care providers.
(b) "Ambulatory health care facility" means a free-standing
facility that provides health care to noninstitutionalized and
nonhomebound persons on an outpatient basis. For purposes of this
definition, a free-standing facility is not located on the campus
of an existing health care facility. This definition does not
include any facility engaged solely in the provision of lithotripsy
services or the private office practice of any one or more health
professionals licensed to practice in this state pursuant to the
provisions of chapter thirty of this code: Provided, That this
exemption from review shall not be construed to include practices
where major medical equipment otherwise subject to review under the
provisions of this article is acquired, offered or developed:
Provided, however, That this exemption from review shall not be
construed to include certain health services otherwise subject to
review under the provisions of subdivision (1), subsection (a),
section four of this article.
(c) "Ambulatory surgical facility" means a free-standing
facility that provides surgical treatment to patients not requiring
hospitalization. For purposes of this definition, a free-standing
facility is not physically attached to a health care facility.
This definition does not include the private office practice of any
one or more health professionals licensed to practice surgery in
this state pursuant to the provisions of chapter thirty of this code: Provided, That this exemption from review shall not be
construed to include practices where major medical equipment
otherwise subject to review under the provisions of this article is
acquired, offered or developed: Provided, however, That this
exemption from review shall not be construed to include health
services otherwise subject to review under the provisions of
subdivision (1), subsection (a), section four of this article.
(d) "Applicant" means: (1) The governing body or the person
proposing a new institutional health service who is, or will be,
the health care facility licensee wherein the new institutional
health service is proposed to be located; and (2) in the case of a
proposed new institutional health service not to be located in a
licensed health care facility, the governing body or the person
proposing to provide the new institutional health service.
Incorporators or promoters who will not constitute the governing
body or persons responsible for the new institutional health
service may not be an applicant.
(e) "Bed capacity" means the number of beds licensed to a
health care facility or the number of adult and pediatric beds
permanently staffed and maintained for immediate use by inpatients
in patient rooms or wards in an unlicensed facility.
(f) "Campus" means the adjacent grounds and buildings, or
grounds and buildings not separated by more than a public right-of-
way, of a health care facility.
(g) "Capital expenditure" means:
(1) An expenditure made by or on behalf of a health care
facility, which:
(A) (i) Under generally accepted accounting principles is not
properly chargeable as an expense of operation and maintenance; or
(ii) is made to obtain either by lease or comparable arrangement
any facility or part thereof or any equipment for a facility or
part; and
(B) (i) Exceeds the expenditure minimum; or (ii) is a
substantial change to the bed capacity of the facility with respect
to which the expenditure is made; or (iii) is a substantial change
to the services of such facility;
(2) The donation of equipment or facilities to a health care
facility, which if acquired directly by that facility would be
subject to review;
(3) The transfer of equipment or facilities for less than fair
market value if the transfer of the equipment or facilities at fair
market value would be subject to review; or
(4) A series of expenditures, if the sum total exceeds the
expenditure minimum and if determined by the state agency to be a
single capital expenditure subject to review. In making this
determination, the state agency shall consider: Whether the
expenditures are for components of a system which is required to
accomplish a single purpose; whether the expenditures are to be
made over a two-year period and are directed towards the
accomplishment of a single goal within the health care facility's long-range plan; or whether the expenditures are to be made within
a two-year period within a single department such that they will
constitute a significant modernization of the department.
(h) "Expenditure minimum" means $2,700,000 for the calendar
year 2009. The state agency shall adjust the expenditure minimum
annually and publish an update of the amount on or before December
31 of each year. The expenditure minimum adjustment shall be based
on the DRI inflation index published in the Global Insight DRI/WEFA
Health Care Cost Review, or its successor or appropriate
replacement index. This amount shall include the cost of any
studies, surveys, designs, plans, working drawings, specifications
and other activities, including staff effort and consulting and
other services essential to the acquisition, improvement, expansion
or replacement of any plant or equipment.
(i) "Health", used as a term, includes physical and mental
health.
(j) "Health care facility" means a publicly or privately owned
facility, agency or entity that offers or provides health care
services, whether a for-profit or nonprofit entity and whether or
not licensed, or required to be licensed, in whole or in part, and
includes, but is not limited to, hospitals; skilled nursing
facilities; kidney disease treatment centers, including free-
standing hemodialysis units; intermediate care facilities;
ambulatory health care facilities; ambulatory surgical facilities;
home health agencies; hospice agencies; rehabilitation facilities; health maintenance organizations; and community mental health and
mental retardation facilities. For purposes of this definition,
"community mental health and mental retardation facility" means a
private facility which provides such comprehensive services and
continuity of care as emergency, outpatient, partial
hospitalization, inpatient or consultation and education for
individuals with mental illness, mental retardation or drug or
alcohol addiction.
(k) "Health care provider" means a person, partnership,
corporation, facility, hospital or institution licensed or
certified or authorized by law to provide professional health care
service in this state to an individual during that individual's
medical, remedial or behavioral health care, treatment or
confinement.
(l) "Health maintenance organization" means a public or
private organization which:
(1) Is required to have a certificate of authority to operate
in this state pursuant to section three, article twenty-five-a,
chapter thirty-three of this code; or
(2) (A) Provides or otherwise makes available to enrolled
participants health care services, including substantially the
following basic health care services: Usual physician services,
hospitalization, laboratory, X ray, emergency and preventive
services and out-of-area coverage;
(B) Is compensated except for copayments for the provision of the basic health care services listed in paragraph (A) of this
subdivision to enrolled participants on a predetermined periodic
rate basis without regard to the date the health care services are
provided and which is fixed without regard to the frequency, extent
or kind of health service actually provided; and
(C) Provides physicians' services: (i) Directly through
physicians who are either employees or partners of the
organization; or (ii) through arrangements with individual
physicians or one or more groups of physicians organized on a group
practice or individual practice basis.
(m) "Health services" means clinically related preventive,
diagnostic, treatment or rehabilitative services, including
alcohol, drug abuse and mental health services.
(n) "Home health agency" means an organization primarily
engaged in providing professional nursing services either directly
or through contract arrangements and at least one of the following
services: Home health aide services, other therapeutic services,
physical therapy, speech therapy, occupational therapy, nutritional
services or medical social services to persons in their place of
residence on a part-time or intermittent basis.
(o) "Hospice agency" means a private or public agency or
organization licensed in West Virginia for the administration or
provision of hospice care services to terminally ill persons in the
persons' temporary or permanent residences by using an
interdisciplinary team, including, at a minimum, persons qualified to perform nursing services; social work services; the general
practice of medicine or osteopathy; and pastoral or spiritual
counseling.
(p) "Hospital" means a facility licensed as such pursuant to
the provisions of article five-b of this chapter, and any acute
care facility operated by the state government, that primarily
provides inpatient diagnostic, treatment or rehabilitative services
to injured, disabled or sick persons under the supervision of
physicians and includes psychiatric and tuberculosis hospitals.
(q) "Intermediate care facility" means an institution that
provides health-related services to individuals with mental or
physical conditions that require services above the level of room
and board, but do not require the degree of services provided in a
hospital or skilled-nursing facility.
(r) "Long-range plan" means a document formally adopted by the
legally constituted governing body of an existing health care
facility or by a person proposing a new institutional health
service which contains the information required by the state agency
in rules adopted pursuant to section eight of this article.
(s) "Major medical equipment" means a single unit of medical
equipment or a single system of components with related functions
which is used for the provision of medical and other health
services and costs in excess of $2,700,000 in the calendar year
2009. The state agency shall adjust the dollar amount specified in
this subsection annually and publish an update of the amount on or before December 31 of each year. The adjustment of the dollar
amount shall be based on the DRI inflation index published in the
Global Insight DRI/WEFA Health Care Cost Review or its successor or
appropriate replacement index. This term does not include medical
equipment acquired by or on behalf of a clinical laboratory to
provide clinical laboratory services if the clinical laboratory is
independent of a physician's office and a hospital and it has been
determined under Title XVIII of the Social Security Act to meet the
requirements of paragraphs ten and eleven, Section 1861(s) of such
act, Title 42 U.S.C. §1395x. In determining whether medical
equipment is major medical equipment, the cost of studies, surveys,
designs, plans, working drawings, specifications and other
activities essential to the acquisition of such equipment shall be
included. If the equipment is acquired for less than fair market
value, the term "cost" includes the fair market value.
(t) "Medically underserved population" means the population of
an area designated by the state agency as having a shortage of
personal health services. The state agency may consider unusual
local conditions that are a barrier to accessibility or
availability of health services. The designation shall be in rules
adopted by the state agency pursuant to section eight of this
article, and the population so designated may include the state's
medically underserved population designated by the Federal
Secretary of Health and Human Services under Section 330(b)(3) of
the Public Health Service Act, as amended, Title 42 U.S.C. §254.
(u) "New institutional health service" means any service as
described in section three of this article.
(v) "Nonhealth-related project" means a capital expenditure
for the benefit of patients, visitors, staff or employees of a
health care facility and not directly related to preventive,
diagnostic, treatment or rehabilitative services offered by the
health care facility. This includes, but is not limited to,
chapels, gift shops, news stands, computer and information
technology systems, educational, conference and meeting facilities,
but excluding medical school facilities, student housing, dining
areas, administration and volunteer offices, modernization of
structural components, boiler repair or replacement, vehicle
maintenance and storage facilities, parking facilities, mechanical
systems for heating, ventilation systems, air conditioning systems
and loading docks.
(w) "Offer", when used in connection with health services,
means that the health care facility or health maintenance
organization holds itself out as capable of providing, or as having
the means to provide, specified health services.
(x) "Person" means an individual, trust, estate, partnership,
committee, corporation, association and other organizations such as
joint-stock companies and insurance companies, a state or a
political subdivision or instrumentality thereof or any legal
entity recognized by the state.
(y) "Physician" means a doctor of medicine or osteopathy legally authorized to practice by the state.
(z) "Proposed new institutional health service" means any
service as described in section three of this article.
(aa) "Psychiatric hospital" means an institution that
primarily provides to inpatients, by or under the supervision of a
physician, specialized services for the diagnosis, treatment and
rehabilitation of mentally ill and emotionally disturbed persons.
(bb) "Rehabilitation facility" means an inpatient facility
operated for the primary purpose of assisting in the rehabilitation
of disabled persons through an integrated program of medical and
other services which are provided under competent professional
supervision.
(cc) "Review agency" means an agency of the state, designated
by the Governor as the agency for the review of state agency
decisions.
(dd) "Skilled nursing facility" means an institution, or a
distinct part of an institution, that primarily provides inpatient
skilled nursing care and related services, or rehabilitation
services, to injured, disabled or sick persons.
(ee) "State agency" means the Health Care Authority created,
established and continued pursuant to article twenty-nine-b of this
chapter. The Executive Director as set forth in section three,
article twenty-nine-b of this chapter, is the administrative head
of the Health Care Authority.
(ff) "State health plan" means the document approved by the Governor after preparation by the former statewide health
coordinating council or that document as approved by the Governor
after amendment by the former health care planning council or the
state agency.
(gg) "Substantial change to the bed capacity" of a health care
facility means any change, associated with a capital expenditure,
that increases or decreases the bed capacity or relocates beds from
one physical facility or site to another, but does not include a
change by which a health care facility reassigns existing beds as
swing beds between acute care and long-term care categories:
Provided, That a decrease in bed capacity in response to federal
rural health initiatives is excluded from this definition.
(hh) "Substantial change to the health services" of a health
care facility means: (1) The addition of a health service offered
by or on behalf of the health care facility which was not offered
by or on behalf of the facility within the twelve-month period
before the month in which the service is first offered; or (2) the
termination of a health service offered by or on behalf of the
facility: Provided, That "substantial change to the health
services" does not include the providing of ambulance service,
wellness centers or programs, adult day care or respite care by
acute care facilities.
(ii) "To develop", when used in connection with health
services, means to undertake those activities which upon their
completion will result in the offer of a new institutional health service or the incurring of a financial obligation in relation to
the offering of such a service.
§16-2D-5. Powers and duties of state agency.
(a) The state agency shall administer the certificate of need
program as provided by this article.
(b) The state agency is responsible for coordinating and
developing the health planning research efforts of the state and
for amending and modifying the state health plan which includes the
certificate of need standards. The state agency shall review the
state health plan, including the certificate of need standards and
make any necessary amendments and modifications. The state agency
shall also review the cost effectiveness of the certificate of need
program. The state agency may form task forces to assist it in
addressing these issues. The task forces shall be composed of
representatives of consumers, business, providers, payers and state
agencies.
(c) The state agency may seek advice and assistance of other
persons, organizations and other state agencies in the performance
of the state agency's responsibilities under this article.
(d) For health services for which competition appropriately
allocates supply consistent with the state health plan, the state
agency shall, in the performance of its functions under this
article, give priority, where appropriate to advance the purposes
of quality assurance, cost effectiveness and access, to actions
which would strengthen the effect of competition on the supply of the services.
(e) For health services for which competition does not or will
not appropriately allocate supply consistent with the state health
plan, the state agency shall, in the exercise of its functions
under this article, take actions, where appropriate to advance the
purposes of quality assurance, cost effectiveness and access and
the other purposes of this article, to allocate the supply of the
services.
(f) Notwithstanding the provisions of section seven of this
article, the state agency may charge a fee for the filing of any
application, the filing of any notice in lieu of an application,
the filing of any exemption determination request or the filing of
any request for a declaratory ruling. The fees charged may vary
according to the type of matter involved, the type of health
service or facility involved or the amount of capital expenditure
involved: Provided, That any fee charged pursuant to this
subsection may not exceed a dollar amount to be established by
procedural rule. The state agency shall evaluate and amend any
procedural rule promulgated prior to the amendments to this
subsection made during the 2009 regular session of the Legislature.
The fees charged shall be deposited into a special fund known as
the Certificate of Need Program Fund to be expended for the
purposes of this article.
(g) A hospital, nursing home or other health care facility may
not add any intermediate care or skilled nursing beds to its current licensed bed complement. This prohibition also applies to
the conversion of acute care or other types of beds to intermediate
care or skilled nursing beds: Provided, That hospitals eligible
under the provisions of section four-a of this article and
subsection (i) of this section may convert acute care beds to
skilled nursing beds in accordance with the provisions of these
sections, upon approval by the state agency. Furthermore, a
certificate of need may not be granted for the construction or
addition of any intermediate care or skilled nursing beds except in
the case of facilities designed to replace existing beds in unsafe
existing facilities. A health care facility in receipt of a
certificate of need for the construction or addition of
intermediate care or skilled nursing beds which was approved prior
to the effective date of this section shall incur an obligation for
a capital expenditure within twelve months of the date of issuance
of the certificate of need. Extensions may not be granted beyond
the twelve-month period. The state agency shall establish a task
force or utilize an existing task force to study the need for
additional nursing facility beds in this state. The study shall
include a review of the current moratorium on the development of
nursing facility beds; the exemption for the conversion of acute
care beds to skilled nursing facility beds; the development of a
methodology to assess the need for additional nursing facility
beds; and certification of new beds both by Medicare and Medicaid.
The task force shall be composed of representatives of consumers, business, providers, payers and government agencies.
(h) An additional intermediate care facility for the mentally
retarded (ICF/MR) beds may not be granted a certificate of need,
except that prohibition does not apply to ICF/MR beds approved
under the Kanawha County circuit court order of August 3, 1989,
civil action number MISC-81-585 issued in the case of E.H. v.
Matin, 168 W.V. 248, 284 S.E. 2d 232 (1981).
(i) Notwithstanding the provisions of subsection (g) of this
section and further notwithstanding the provisions of subsection
(b), section three of this article, an existing acute care hospital
may apply to the Health Care Authority for a certificate of need to
convert acute care beds to skilled nursing beds: Provided, That
the proposed skilled nursing beds are Medicare certified only:
Provided, however, That any hospital which converts acute care beds
to Medicare certified only skilled nursing beds shall not bill for
any Medicaid reimbursement for any converted beds. In converting
beds, the hospital shall convert a minimum of one acute care bed
into one Medicare certified only skilled nursing bed. The Health
Care Authority may require a hospital to convert up to and
including three acute care beds for each Medicare certified only
skilled nursing bed: Provided further, That a hospital designated
or provisionally designated by the state agency as a rural primary
care hospital may convert up to thirty beds to a distinct-part
nursing facility, including skilled nursing beds and intermediate
care beds, on a one-for-one basis if the rural primary care hospital is located in a county without a certified freestanding
nursing facility and the hospital may bill for Medicaid
reimbursement for the converted beds: And provided further, That
if the hospital rejects the designation as a rural primary care
hospital, then the hospital may not bill for Medicaid
reimbursement. The Health Care Authority shall adopt rules to
implement this subsection which require that:
(1) All acute care beds converted shall be permanently deleted
from the hospital's acute care bed complement and the hospital may
not thereafter add, by conversion or otherwise, acute care beds to
its bed complement without satisfying the requirements of
subsection (b), section three of this article for which purposes an
addition, whether by conversion or otherwise, shall be considered
a substantial change to the bed capacity of the hospital
notwithstanding the definition of that term found in subsection
(ff), section two of this article.
(2) The hospital shall meet all federal and state licensing
certification and operational requirements applicable to nursing
homes including a requirement that all skilled care beds created
under this subsection shall be located in distinct-part, long-term
care units.
(3) The hospital shall demonstrate a need for the project.
(4) The hospital shall use existing space for the Medicare
certified only skilled nursing beds. Under no circumstances shall
the hospital construct, lease or acquire additional space for purposes of this section.
(5) The hospital shall notify the acute care patient, prior to
discharge, of facilities with skilled nursing beds which are
located in or near the patient's county of residence. Nothing in
this subsection negatively affects the rights of inspection and
certification which are otherwise required by federal law or
regulations or by this code or duly adopted rules of an authorized
state entity.
(j) (1) Notwithstanding the provisions of subsection (g) of
this section, a retirement life care center with no skilled nursing
beds may apply to the Health Care Authority for a certificate of
need for up to sixty skilled nursing beds provided the proposed
skilled beds are Medicare certified only. On a statewide basis, a
maximum of one hundred eighty skilled beds which are Medicare
certified only may be developed pursuant to this subsection. The
state health plan is not applicable to projects submitted under
this subsection. The Health Care Authority shall adopt rules to
implement this subsection which shall include a requirement that:
(A) The one hundred eighty beds are to be distributed on a
statewide basis;
(B) There be a minimum of twenty beds and a maximum of sixty
beds in each approved unit;
(C) The unit developed by the retirement life care center
meets all federal and state licensing certification and operational
requirements applicable to nursing homes;
(D) The retirement center demonstrates a need for the project;
(E) The retirement center offers personal care, home health
services and other lower levels of care to its residents; and
(F) The retirement center demonstrates both short- and long-
term financial feasibility.
(2) Nothing in this subsection negatively affects the rights
of inspection and certification which are otherwise required by
federal law or regulations or by this code or duly adopted rules of
an authorized state entity.
(k) The state agency may order a moratorium upon the offering
or development of a new institutional health service when criteria
and guidelines for evaluating the need for the new institutional
health service have not yet been adopted or are obsolete. The
state agency may also order a moratorium on the offering or
development of a health service, notwithstanding the provisions of
subdivision (5), subsection (b), section three of this article,
when it determines that the proliferation of the service may cause
an adverse impact on the cost of health care or the health status
of the public. A moratorium shall be declared by a written order
which shall detail the circumstances requiring the moratorium.
Upon the adoption of criteria for evaluating the need for the
health service affected by the moratorium, or one hundred eighty
days from the declaration of a moratorium, whichever is less, the
moratorium shall be declared to be over and applications for
certificates of need are processed pursuant to section six of this article.
(l) (1) The state agency shall coordinate the collection of
information needed to allow the state agency to develop recommended
modifications to certificate of need standards as required in this
article. When the state agency proposes amendments or
modifications to the certificate of need standards, it shall file
with the Secretary of State, for publication in the State Register,
a notice of proposed action, including the text of all proposed
amendments and modifications, and a date, time and place for
receipt of general public comment. To comply with the public
comment requirement of this section, the state agency may hold a
public hearing or schedule a public comment period for the receipt
of written statements or documents.
(2) When amending and modifying the certificate of need
standards, the state agency shall identify relevant criteria
contained in section six of this article or rules adopted pursuant
to section eight of this article and apply those relevant criteria
to the proposed new institutional health service in a manner that
promotes the public policy goals and legislative findings contained
in section one of this article. In doing so, the state agency may
consult with or rely upon learned treatises in health planning,
recommendations and practices of other health planning agencies and
organizations, recommendations from consumers, recommendations from
health care providers, recommendations from third-party payors,
materials reflecting the standard of care, the state agency's own developed expertise in health planning, data accumulated by the
state agency or other local, state or federal agency or
organization and any other source deemed relevant to the
certificate of need standards proposed for amendment or
modification.
(3) All proposed amendments and modifications to the
certificate of need standards, with a record of the public hearing
or written statements and documents received pursuant to a public
comment period, shall be presented to the Governor. Within thirty
days of receiving the proposed amendments or modifications, the
Governor shall either approve or disapprove all or part of the
amendments and modifications and, for any portion of amendments or
modifications not approved, shall specify the reason or reasons for
nonapproval. Any portions of the amendments or modifications not
approved by the Governor may be revised and resubmitted.
(4) The certificate of need standards adopted pursuant to this
section which are applicable to the provisions of this article are
not subject to article three, chapter twenty-nine-a of this code.
The state agency shall follow the provisions set forth in this
subsection for giving notice to the public of its actions, holding
hearings or receiving comments on the certificate of need
standards. The certificate of need standards in effect on November
29, 2005, and all prior versions promulgated and adopted in
accordance with the provisions of this section are and have been in
full force and effect from each of their respective dates of approval by the Governor.
(m) The state agency may exempt from or expedite rate review,
certificate of need and annual assessment requirements and issue
grants and loans to financially vulnerable health care facilities
located in underserved areas that the state agency and the Office
of Community and Rural Health Services determine are collaborating
with other providers in the service area to provide cost effective
health care services.
ARTICLE 5F. HEALTH CARE FINANCIAL DISCLOSURE.
§16-5F-2. Definitions.
As used in this article:
(1) "Annual report" means an annual financial report for the
covered facility's or related organization's fiscal year prepared
by an accountant or the covered facility's or related
organization's auditor.
(2) "Board" "Authority" means the West Virginia Health Care
Cost Review Authority.
(3) "Covered facility" means any hospital, skilled nursing
facility, kidney disease treatment center, including a
free-standing hemodialysis unit; intermediate care facility;
ambulatory health care facility; ambulatory surgical facility; home
health agency; hospice agency; rehabilitation facility; health
maintenance organization; or community mental health or mental
retardation facility, whether under public or private ownership or
as a profit or nonprofit organization and whether or not licensed or required to be licensed in whole or in part by the state:
Provided, That nonprofit, community-based primary care centers
providing primary care services without regard to ability to pay
which provide the board authority with a year-end audited financial
statement prepared in accordance with generally accepted auditing
standards and with governmental auditing standards issued by the
Comptroller General of the United States shall be deemed to have
complied with the disclosure requirements of this section.
(4) "Related organization" means an organization, whether
publicly owned, nonprofit, tax-exempt or for profit, related to a
covered facility through common membership, governing bodies,
trustees, officers, stock ownership, family members, partners or
limited partners, including, but not limited to, subsidiaries,
foundations, related corporations and joint ventures. For the
purposes of this subdivision "family members" shall mean brothers
and sisters whether by the whole or half blood, spouse, ancestors
and lineal descendants.
(5) "Rates" means all rates, fees or charges imposed by any
covered facility for health care services.
(6) "Records" includes accounts, books, charts, contracts,
documents, files, maps, papers, profiles, reports, annual and
otherwise, schedules and any other fiscal data, however recorded or
stored.
§16-5F-3. General powers and duties of the Health Care Authority
regarding reporting and review.
(a) In addition to the powers granted to the board authority
elsewhere in this article, the board authority shall have the
powers as indicated by this section and it shall be its duty to:
(1) Promulgate legislative rules and regulations in accordance
with the provisions of article three, chapter twenty-nine-a of this
code, to implement and make effective the powers, duties and
responsibilities contained in the provisions of this article.
(2) Require the filing of fiscal information by covered
facilities and related organizations relating to any matter
affecting the cost of health care services in this state.
(3) Exercise, subject to the limitations and restrictions
herein imposed, all other powers which are reasonably necessary or
essential to carry out the expressed purposes of this article.
(4) Require the filing of copies of all tax returns required
by federal and state law to be filed by covered facilities and
related organizations.
(b) The board authority shall also investigate and recommend
to the Legislature whether other health care providers should be
made subject to the provisions of this article.
(c) The board authority shall, not later than December 31 of
each year, prepare and transmit to the Governor and to the clerks
of both houses of the Legislature a report containing the material
and data as required by section four of this article, based upon
the most recent data available.
The board shall, no later than the first day of July, one thousand nine hundred ninety-two, prepare and transmit to the
Governor and to the clerks of both houses of the Legislature a
special report containing the material and data collected on
related organizations. The report shall further explain the effect
of the financial activities of the related organizations as
represented by the collected data and its relationship to the rate
setting powers of the board specified in section nineteen, article
twenty-nine-b of this chapter.
§16-5F-4. Reports required to be published and filed; form of
reports; right of inspection.
(a) Every covered facility and related organization defined in
this article, within one hundred twenty days after the end of each
of their fiscal years, unless an extension be granted by the board
authority for good cause shown, shall be required to file with the
board authority and publish, as a Class I legal advertisement,
pursuant to section two, article three, chapter fifty-nine of the
Code of West Virginia, in a qualified newspaper published within
the county within which such covered facility or related
organization is located, an annual report prepared by the covered
facility's or related organization's auditor or an independent
accountant.
Such report shall contain a complete statement of the
following:
(1) Assets and liabilities;
(2) Income and expenses;
(3) Profit or loss for the period reported;
(4) A statement of ownership for persons owning more than five
percent of the capital stock outstanding and the dividends paid
thereon, if any, and to whom paid for the period reported unless
the covered facility or related organization be duly registered on
the New York Stock Exchange, American Stock Exchange, any regional
stock exchange, or its stock traded actively over the counter.
Such statement shall further contain a disclosure of ownership by
any parent company or subsidiary, if applicable.
Such annual report shall also include a prominent notice that
the details concerning the contents of the advertisement, together
with the other reports, statements and schedules required to be
filed with the board authority by the provisions of this section,
shall be available for public inspection and copying at the board's
authority's office.
(b) Every covered facility and related organization shall also
file with the board authority the following statements, schedules
or reports in such form and at such intervals as may be specified
by the, board authority
but at least annually:
(1) A statement of services available and services rendered;
(2) A statement of the total financial needs of such covered
facility or related organization and the resources available or
expected to become available to meet such needs;
(3) A complete schedule of such covered facility's or related
organization's then current rates with costs allocated to each category of costs, in accordance with the rules and regulations as
promulgated by the board authority
pursuant to section three
hereof;
(4) A copy of such reports made or filed with the federal
Health Care Financing Administration, or its successor, as the
board authority
may deem necessary or useful to accomplish the
purposes of this article;
(5) A statement of all charges, fees or salaries for goods or
services rendered to the covered facility or related organization
for the period reported which shall exceed in total the sum of
$55,000 and a statement of all charges, fees or other sums
collected by the covered facility or related organization for or on
the account of any person, firm, partnership, corporation or other
entity, however structured, which shall exceed in total the sum of
$55,000 during the period reported;
(6) Such other reports of the costs incurred in rendering
services as the board authority
may prescribe. The board authority
may require the certification of specified financial reports by the
covered facility's or related organization's auditor or independent
accountant; and
(7) A copy of all tax returns required to be filed by federal
and state law.
(c) Notwithstanding any provision to the contrary herein, any
data or material that is furnished to the board authority
pursuant
to the provisions of subdivision (4), subsection (b) of this section need not be duplicated by any other requirements of this
section requiring the filing of data and material.
(d) No report, statement, schedule or other filing required or
permitted to be filed hereunder shall contain any medical or
individual information personally identifiable to a patient or a
consumer of health services, whether directly or indirectly. All
such reports, statements and schedules filed with the board
authority
under this section shall be open to public inspection and
shall be available for examination during regular hours. Copies of
such reports shall be made available to the public upon request and
the board authority may establish fees reasonably calculated to
reimburse the board authority
for its actual costs in making
copies of such reports: Provided, That all tax returns filed
pursuant to this article shall be confidential and it shall be
unlawful for the board authority
or any member of its staff to
divulge or make known in any manner the tax return, or any part
thereof, of any covered facility or related organization.
(e) Whenever further fiscal information is deemed necessary to
verify the accuracy of any information set forth in any statement,
schedule or report filed by a covered facility or related
organization under the provisions of this article, the board
authority
shall have the authority to require the production of any
records necessary to verify such information.
(f) From time to time, the board authority
shall engage in or
carry out analyses and studies relating to health care costs, the financial status of any covered facility or related organization or
any other appropriate related matters, and make determinations of
whether, in its opinion, the rates charged by a covered facility
are economically justified.
§16-5F-5. Injunctions.
Whenever it appears that any covered facility or related
organization, required to file or publish such reports, as provided
in this article, has failed to file or publish such reports, the
Attorney General, upon the request of the board authority, may
apply in the name of the state to, and the circuit court of the
county in which such covered facility or related organization is
located shall have jurisdiction for the granting of a mandatory
injunction to compel compliance with the provisions of this
article.
§16-5F-6. Failure to make, publish or distribute reports;
penalty; appeal to Supreme Court of Appeals.
Every covered facility and related organization failing to
make and transmit to the board authority any of the reports
required by law or failing to publish or distribute the reports as
so required, shall forthwith be notified by the board authority
and, if such failure continues for ten days after receipt of said
notice, such delinquent facility or organization shall be subject
to a penalty of $1,000 for each day thereafter that such failure
continues, such penalty to be recovered by the board authority
through the Attorney General in a civil action and paid into the State Treasury to the account of the General Fund. Review of any
final judgment or order of the circuit court shall be by appeal to
the West Virginia Supreme Court of Appeals.
ARTICLE 29B. HEALTH CARE AUTHORITY.
§16-29B-3. Definitions.
Definitions of words and terms defined in articles two-d and
five-f of this chapter are incorporated in this section unless this
section has different definitions.
As used in this article, unless a different meaning clearly
appears from the context:
(a) "Authority" means the Health Care Authority created
pursuant to the provisions of this article, an autonomous division
within the state Department of Health and Human Resources.
(b) "Board" means the five-member board of directors of the
West Virginia Health Care Authority;
(a) (c) "Charges" means the economic value established for
accounting purposes of the goods and services a hospital provides
for all classes of purchasers;
(b) (d) "Class of purchaser" means a group of potential
hospital patients with common characteristics affecting the way in
which their hospital care is financed. Examples of classes of
purchasers are Medicare beneficiaries, welfare recipients,
subscribers of corporations established and operated pursuant to
article twenty-four, chapter thirty-three of this code, members of
health maintenance organizations and other groups as defined by the board authority;
(c) "Board" means the three-member board of directors of the
West Virginia Health Care Authority, an autonomous division within
the state Department of Health and Human Resources;
(e) "Executive Director" or "Director" means the Executive
Director who is the administrative head of the Health Care
Authority as set forth in section five-a of this article.
(d) (f) "Health care provider" means a person, partnership,
corporation, facility, hospital or institution licensed, certified
or authorized by law to provide professional health care service in
this state to an individual during this individual's medical,
remedial, or behavioral health care, treatment or confinement. For
purposes of this article, "health care provider" shall not include
the private office practice of one or more health care
professionals licensed to practice in this state pursuant to the
provisions of chapter thirty of this code.
(e) (g) "Hospital" means a facility subject to licensure as
such under the provisions of article five-b of this chapter, and
any acute care facility operated by the state government which is
primarily engaged in providing to inpatients, by or under the
supervision of physicians, diagnostic and therapeutic services for
medical diagnosis, treatment and care of injured, disabled or sick
persons, and does not include state mental health facilities or
state long-term care facilities;
(f) (h) "Person" means an individual, trust, estate, partnership, committee, corporation, association or other
organization such as a joint stock company, a state or political
subdivision or instrumentality thereof or any legal entity
recognized by the state;
(g) (i) "Purchaser" means a consumer of patient care services,
a natural person who is directly or indirectly responsible for
payment for such patient care services rendered by a health care
provider, but does not include third-party payers;
(h) (j) "Rates" means all value given or money payable to
health care providers for health care services, including fees,
charges and cost reimbursements;
(i) (k) "Records" means accounts, books and other data related
to health care costs at health care facilities subject to the
provisions of this article which do not include privileged medical
information, individual personal data, confidential information,
the disclosure of which is prohibited by other provisions of this
code and the laws enacted by the federal government, and
information, the disclosure of which would be an invasion of
privacy;
(l) "Related organization" means an organization, whether
publicly owned, nonprofit, tax-exempt or for profit, related to a
health care provider through common membership, governing bodies,
trustees, officers, stock ownership, family members, partners or
limited partners including, but not limited to, subsidiaries,
foundations, related corporations and joint ventures. For the purposes of this subsection family members shall mean brothers and
sisters, whether by the whole or half blood, spouse, ancestors and
lineal descendants;
(j) (m) "Third-party payor" means any natural person, person,
corporation or government entity responsible for payment for
patient care services rendered by health care providers. and
(k) "Related organization" means an organization, whether
publicly owned, nonprofit, tax-exempt or for profit, related to a
health care provider through common membership, governing bodies,
trustees, officers, stock ownership, family members, partners or
limited partners including, but not limited to, subsidiaries,
foundations, related corporations and joint ventures. For the
purposes of this subsection family members shall mean brothers and
sisters, whether by the whole or half blood, spouse, ancestors and
lineal descendants.
§16-29B-5. West Virginia Health Care Authority; composition of
the board; qualifications; terms; oath;
compensation and expenses of members; vacancies;
and meetings of the board.
The "West Virginia Health Care Cost Review Authority" is
continued as an autonomous division of the Department of Health and
Human Resources and shall be known as The "West Virginia Health
Care Authority" is an autonomous division of the Department of
Health and Human Resources and is hereinafter referred to as the
"board" the "authority". The Board of Directors of the West Virginia Health Care Authority shall hereinafter be referred to as
the "board". Any references in this code to the West Virginia
health care cost review authority means the West Virginia Health
Care Authority.
(a) The board shall consist of three five members, appointed
by the Governor, with the advice and consent of the Senate. The
members of the board shall be employed on a part time basis. The
board members shall not be permitted to hold political office in
the government of the state either by election or appointment while
serving as a member of the board. The board members shall not be
eligible for civil service coverage as provided in section four,
article six, chapter twenty-nine of this code. The board members
shall be citizens and residents of this state. No more than two
three of the board members may be members of the same political
party. One board member shall have a background in health care
finance or economics, one board member shall have previous
employment experience in human services, business administration or
substantially related fields, one board member shall have previous
experience in the administration of a health care facility, one
board member shall have previous experience as a provider of health
care services, and one board member shall be a consumer of health
services with a demonstrated interest in health care issues.
(b) Each board member shall, before entering upon the duties
of his or her office, take and subscribe to the oath provided by
section five, article IV of the Constitution of the State of West Virginia, which oath shall be filed in the office of the Secretary
of State. The Governor shall designate one of the board members to
serve as chairman at the Governor's will and pleasure. The
chairman shall be the chief administrative officer of the board.
(c) The Governor may remove any board member only for
incompetency, neglect of duty, gross immorality, malfeasance in
office or violation of the provisions of this article.
Appointments are for terms of six years, except that an appointment
to fill a vacancy shall be for the unexpired term only.
(c) (d) No person while in the employ of, or holding any
official relation to, any hospital or health care provider subject
to the provisions of this article, or who has any pecuniary
interest in any hospital or health care provider, may serve as a
member of the board or as an employee of the board. Nor may any
board member be a candidate for or hold public office or be a
member of any political committee while acting as a board member;
nor may any board member or employee of the board receive anything
of value, either directly or indirectly, from any third-party payor
or health care provider. If any of the board members become a
candidate for any public office or for membership on any political
committee, the Governor shall remove the board member from the
board and shall appoint a new board member to fill the vacancy
created. No board member or former board member may accept
employment with any hospital or health care provider subject to the
jurisdiction of the board in violation of the West Virginia governmental ethics act, chapter six-b of this code: Provided,
That the act shall not apply to employment accepted after
termination of the board.
(d) (e) The concurrent judgment of two three of the board
members when in session as the board shall be considered the action
of the board. A vacancy in the board shall not affect the right or
duty of the remaining board members to function as a board.
(f) The board is under the direct supervision of the Executive
Director. The Executive Director shall serve as the ex officio,
nonvoting chair of the board. The board shall serve as the
adjudicatory body of the authority and shall conduct all hearings
as required in this article, article two-d of this chapter and any
other hearing as required by this code or any legislative or
procedural rule of the authority. The Executive Director shall act
as hearing examiner for all hearings before the board.
(g) The board shall advice the Executive Director created in
section five-a of this article on matters relative to the
administration of the authority. This shall include contracting
authority, staffing, rulemaking and data collection and
interpretation.
(h) Board members are entitled to receive from the authority's
funds as compensation for his or her services an annual salary of
$15,000. Board members shall also be reimbursed from the
authority's funds for sums necessary to carry out its
responsibilities and for reasonable travel expenses to attend meetings.
§16-29B-5a. Executive Director of the Health Care Authority;
powers and duties.
(a) The Governor, with advice and consent of the Senate,
shall appoint an individual as Executive Director of the Health
Care Authority. This person shall oversee the daily operation of
the Health Care Authority. This person shall be qualified by
training and experience to direct the operations of the Health Care
Authority. The Executive Director is ineligible for civil service
coverage as provided in section four, article six, chapter
twenty-nine of this code and serves at the will and pleasure of the
Governor.
(b) The Executive Director shall:
(1) Serve on a full time basis and may not be engaged in any
other profession or occupation;
(2) Not hold political office in the government of the state
either by election or appointment while serving as Executive
Director;
(3) Shall be a citizen of the United States and shall become
a citizen of the state within ninety days of appointment; and
(4) Before entering upon the duties of his or her office,
take and subscribe to the oath provided by section five, article IV
of the Constitution of the State of West Virginia, which oath shall
be filed in the office of the Secretary of State.
(c) The Executive Director has other powers and duties as set forth in this article.
§16-29B-6. Information gathering and coordination; data advisory
group.
(a) The Executive Director with advice from the board shall:
Coordinate and oversee the health data collection of state
agencies; lead state agencies' efforts to make the best use of
emerging technology to effect the expedient and appropriate
exchange of health care information and data, including patient
records and reports; and coordinate database development, analysis
and reporting to facilitate cost management, utilization review and
quality assurance efforts by state payor and regulatory agencies,
insurers, consumers, providers and other interested parties.
Agencies of the state collecting health data shall work together
through the board Executive Director to develop an integrated
system for the efficient collection, responsible use and
dissemination of such data and to facilitate and support the
development of statewide health information systems that will allow
for the electronic transmittal of all health information and claims
processing activities of state agencies within the state and that
will coordinate the development and use of electronic health
information systems within state government. The Executive
Director with advice from the board shall establish minimum
requirements and issue reports relating to information systems of
all state health programs, including simplifying and standardizing
forms, establishing information standards and reports for capitated managed care programs to be managed by the Insurance Commission
Office of the Insurance Commissioner, and shall develop a
comprehensive system to collect ambulatory health care data. The
board Executive Director or his or her designee is authorized to
gain access to any health-related database in state government for
the purposes of fulfilling its duties: Provided, That, for any
database to which the board Executive Director gains access, the
use and dissemination of information from the database shall be
subject to the confidentiality provisions applicable to such
database.
(b) To advise the Executive Director and the board in its
efforts under this section, the board Executive Director or his or
her designee shall create a data advisory group. and appoint one
of the board's members as chair of the group The Executive
Director or his or her designee shall be the chair of the group.
The group shall be composed of representatives of consumers,
businesses, providers, payors and state agencies. At least one of
the members shall represent the interest of hospitals which are
regulated by the Health Care Authority. The data advisory group
shall assist the Executive Director and the board in developing
priorities and protocols for data collection and the development
and reform of health information systems provided under this
section.
(c) The board's staff of the Health Care Authority shall
gather information on cost containment efforts, including, but not limited to, the provision of alternative delivery systems,
prospective payment systems, alternative rate-making methods, and
programs of consumer education. The board authority shall pay
particular attention to the economic, quality of care and health
status impact of such efforts on purchasers or classes of
purchasers, particularly the elderly and those on low or fixed
incomes.
(d) The board authority staff shall further gather information
on state-of-the-art advances in medical technology, the cost
effectiveness of such advances and their impact on advances in
health care services and management practices, and any other
state-of-the-art concepts relating to health care cost containment,
health care improvement or other issues the board authority finds
relevant and directs staff to investigate. The board authority
staff shall prepare and keep a register of such information and
update it on an annual basis.
(e) The data advisory group members shall be reimbursed from
the board authority's funds for sums necessary to carry out its
responsibilities and for reasonable travel expenses to attend
meetings.
§16-29B-7. Staff.
(a) The Executive Director with advice from the board may
employ such persons as may be necessary to effect the provisions of
this article. The Executive Director with advice from the board
shall set the respective salaries or compensations of all staff. Any person employed by the board Health Care Authority other than
on a part-time basis shall devote full time to the performance of
his or her duties as such employee during the regular working hours
of the board authority.
(b) The board Executive Director shall appoint a general
counsel who shall act as legal counsel to the Executive Director
and the board. The general counsel shall serve at the will and
pleasure of the board Executive Director and is not eligible for
civil service coverage as provided in section four, article six,
chapter twenty-nine of this code.
(1) The general counsel may act to bring and to defend actions
on behalf of the authority and the board in the courts of the state
and in federal courts.
(2) In all adjudicative matters before the board, the general
counsel shall present the matter before the board and offer legal
and administrative
advice to the board. The staff shall represent
itself in all such actions before the board.
(c) The board Executive Director may contract with third
parties, including state agencies, for any services that may be
necessary to perform the duties imposed upon it him or her by this
article where such contractual agreements will promote economy,
avoid duplication of effort or make the best use of available
expertise.
(d) The Executive Director with advice from the board shall
identify which members of the staff of the health care cost review authority shall be exempted from the salary schedules or pay plan
adopted by the state personnel board, and further identify such
staff members by job classification or designation, together with
the salary or salary ranges for each such job classification or
designation. This information shall be filed by the board
Executive Director or his or her designee with the director of the
Division of Personnel no later than July 1 one thousand nine
hundred ninety-one, and thereafter as necessary of every year as
necessary.
§16-29B-8. Powers generally; budget expenses of the Executive
Director and the board.
(a) In addition to the powers granted to the board Executive
Director elsewhere in this article, the Executive Director with
advice from the board may:
(1) Adopt, amend and repeal necessary, appropriate and lawful
policy guidelines, and legislative rules promulgated in accordance
with article three, chapter twenty-nine-a of this code and any
procedural rules of the authority: Provided, That subsequent
amendments and modifications to any legislative rule promulgated
pursuant to this article and not exempt from the provisions of
article three, chapter twenty-nine-a of this code may be
implemented by emergency rule;
(2) Hold public hearings, conduct investigations and require
the filing of information relating to matters affecting the costs
of health care services subject to the provisions of this article and may subpoena witnesses, papers, records, documents and all
other data in connection therewith. The board, who serves as the
adjudicatory arm of the authority, may administer oaths or
affirmations in any hearing or investigation;
(3) Apply for, receive and accept gifts, payments and other
funds and advances from the United States, the state or any other
governmental body, agency or agencies or from any other private or
public corporation or person (with the exception of hospitals
subject to the provisions of this article, or associations
representing them, doing business in the State of West Virginia,
except in accordance with subsection (c) of this section), and
enter into agreements with respect thereto, including the
undertaking of studies, plans, demonstrations or projects. Any
such gifts or payments that may be received or any such agreements
that may be entered into shall be used or formulated only so as to
pursue legitimate, lawful purposes of the board authority, and
shall in no respect inure to the private benefit of the Executive
Director, a board member, staff member, donor or contracting party;
(4) Lease, rent, acquire, purchase, own, hold, construct,
equip, maintain, operate, sell, encumber and assign rights or
dispose of any property, real or personal, consistent with the
objectives of the board authority as set forth in this article:
Provided, That such acquisition or purchase of real property or
construction of facilities shall be consistent with planning by the
state building commissioner and subject to the approval of the Legislature;
(5) Contract and be contracted with and execute all
instruments necessary or convenient in carrying out the board's
authority's functions and duties; and
(6) Exercise, subject to limitations or restrictions herein
imposed, all other powers which are reasonably necessary or
essential to effect the express objectives and purposes of this
article.
(b) The Executive Director with advice from the board shall
annually prepare a budget for the next fiscal year for submission
to the Governor and the Legislature which shall include all sums
necessary to support the activities of the Executive Director,
board and its staff staff of the authority.
(c) Each hospital subject to the provisions of this article
shall be assessed by the Executive Director with advice from the
board on a pro rata basis using the gross revenues of each hospital
as reported under the authority of section eighteen of this article
as the measure of the hospital's obligation. The amount of such
fee shall be determined by the Executive Director with advice from
the board except that in no case shall the hospital's obligation
exceed one tenth of one percent of its gross revenue. Such fees
shall be paid on or before July 1 in each year and shall be paid
into the State Treasury and kept as a special revolving fund
designated "Health Care Cost Review Fund", with the moneys in such
fund being expendable after appropriation by the Legislature for purposes consistent with this article. Any balance remaining in
said fund at the end of any fiscal year shall not revert to the
treasury, but shall remain in said fund and such moneys shall be
expendable after appropriation by the Legislature in ensuing fiscal
years.
(d) Each hospital's assessment shall be treated as an
allowable expense by the board authority.
(e) The board authority is empowered to withhold rate
approvals, certificates of need and rural health system loans and
grants if any such fees remain unpaid, unless exempted under
subsection (g), section four, article two-d of this chapter.
§16-29B-9. Annual report.
The board Executive Director shall, within thirty days of the
close of the fiscal year, or from time to time as requested by the
Legislature, prepare and transmit to the Governor and the
Legislative Oversight Commission on Health and Human Resources
accountability a report of its operations and activities for the
preceding fiscal year. This report shall include summaries of all
reports made by the hospitals subject to this article, together
with facts, suggestions and policy recommendations the board
authority considers necessary. The board shall, after rate review
and determination in accordance with the provisions of this
article, include such rate schedules in its annual report or other
reports as may be requested by the Legislature.
§16-29B-10. Elimination of rate review.
(a) Notwithstanding any other provision of this code or state
law, after July 1, one thousand nine hundred eighty-four 2010, the
jurisdiction of the board or authority as to rates for health
services care shall cease to exists. extend to all hospitals as
defined herein doing business in the State of West Virginia (with
the exception of hospitals owned and operated by the federal
government).
(b) Those costs or charges associated with individual health
care providers or health care provider groups providing inpatient
or outpatient services under a contractual agreement with hospitals
(excluding simple admitting privileges) shall be under the
jurisdiction of the board authority. The jurisdiction of the board
authority shall not extend to the regulation of rates of private
health care providers or health care groups providing inpatient or
outpatient services under a contractual agreement with hospitals
when the provision of such service is outside the hospital setting,
and shall not extend to the regulation of rates of all other
private health care providers practicing outside the hospital
setting: Provided, That such practice outside of the hospital
setting is not found to be an evasion of the purposes of this
article.
§16-29B-11. Related programs.
In addition to carrying out its duties under this article, the
board authority shall carry out its information disclosure
functions set forth in article five-f of this chapter and its functions set forth in article two-d of this chapter, including
health planning, issuing grants and loans to financially vulnerable
health care entities located in underserved areas, and the review
and approval or disapproval of capital expenditures for health care
facilities or services. In making decisions in the certificate of
need review process, the board authority shall be guided by the
state health plan approved by the Governor.
§16-29B-12. Hearings; administrative procedures act applicable;
hearings examiner; subpoenas.
(a) The board Health Care Authority may conduct such hearings
as it deems necessary for the performance of its functions and
shall hold hearings when required by the provisions of this chapter
or upon a written demand therefor by a person aggrieved by any act
or failure to act by the board Health Care Authority or by any
legislative or procedural rule regulation or order of the board
Health Care Authority. All hearings of the board Health Care
Authority shall be announced in a timely manner and shall be open
to the public except as may be necessary to conduct business of an
executive nature. All hearings shall be conducted by the board of
Directors who shall serve as the adjudicatory arm of the Health
Care Authority. The Executive Director shall serve as the hearing
examiner and shall preside over all hearings before the board.
(b) All pertinent provisions of article five, chapter
twenty-nine-a of this code shall apply to and govern the hearing
and administrative procedures in connection with and following the hearing except as specifically stated to the contrary in this
article. The Executive Director shall assure that all hearings are
to be conducted in a professional and respectful manner. The
Executive Director, board members and all other participants
involved in the hearing shall be courteous to those persons who
appear before them and shall carefully examine all evidence and
information presented. The General Counsel for the Authority shall
represent the interest of the Authority at all hearings. No board
member or the Executive Director may participate in a decision
unless he or she has heard all of the information presented during
the course of the hearing. If necessary, recesses in the hearing
may be called. Decisions of the board shall be issued by the
Executive Director as the hearing examiner for all hearings before
the board pursuant to the provisions of this article.
(c) Any hearing may be conducted by members of the board or by
a hearing examiner appointed for such purpose the Executive
Director or his or her designee. Any member of the board The
Executive Director may issue subpoenas and subpoenas duces tecum
which shall be issued and served pursuant to the time, fee and
enforcement specifications in section one, article five, chapter
twenty-nine-a of this code.
(d) Notwithstanding any other provision of state law, when a
hospital alleges that a factual determination made by the board or
the Executive Director is incorrect, the burden of proof shall be
on the hospital to demonstrate that such determination is, in light of the total record, not supported by substantial evidence. The
burden of proof remains with the hospital in all cases.
(e) After any hearing, after due deliberation, and in
consideration of all the testimony, the evidence and the total
record made, the board as the adjudicatory arm of the authority
shall render a recommended decision in writing to the Executive
Director. The recommended written decision shall be accompanied by
findings of fact and conclusions of law as specified in section
three, article five, chapter twenty-nine-a of this code, and
forwarded to the Executive Director within thirty days of the
hearing. The Executive Director shall approve the recommended
decision as final within thirty days of receipt unless he or she
finds a factual or legal error in the decision's findings or
conclusions. If The Executive Director feels that there is
insufficient information upon which to base the decision, he or she
may remand the decision to the board for further consideration.
The Executive Director may not consider any additional information
in making the decision final that was not presented to the board
during the course of the hearing. Once the Executive Director
approves the decision as final the copy of the decision and
accompanying findings and conclusions shall be served by certified
mail, return receipt requested, upon the party demanding the
hearing, and upon its attorney of record, if any.
(f) Any interested individual, group or organization shall be
recognized as affected parties upon written request from the individual, group or organization. Affected parties shall have the
right to bring relevant evidence before the board and testify
thereon. Affected parties shall have equal access to records,
testimony and evidence before the board authority, and shall have
equal access to the expertise of the board's authority's staff.
The Executive Director with advice from the board shall have
authority to develop procedural rules and regulations to administer
provisions of this section.
(g) The decision of the board Executive Director is final
unless reversed, vacated or modified upon judicial review thereof,
in accordance with the provisions of section thirteen of this
article.
§16-29B-13. Review of final orders of Executive Director.
(a) A final decision of the board Executive Director and the
record upon which it was made shall, upon request of any affected
party, be reviewed by the agency of the state designated by the
Governor to hear appeals under the provisions of article two-d of
this chapter. To be effective, such request must be received
within thirty days after the date upon which all parties received
notice of the board Executive Director's final decision, and the
hearing shall commence within thirty days of receipt of the
request.
(b) For the purpose of administrative review of board
Executive Director decisions, the review agency shall conduct its
proceedings in conformance with the West Virginia rules of civil procedure for trial courts of record and the local rules for use in
the civil courts of Kanawha County and shall review appeals in
accordance with the provisions governing the judicial review of
contested administrative cases in section four, article five,
chapter twenty-nine-a of this code, notwithstanding the exceptions
of section five, article five, chapter twenty-nine-a of this code.
(c) The decision of the review agency shall be made in writing
within forty-five days after the conclusion of such hearing.
(d) The written findings of the review agency shall be sent to
all affected parties, and shall be made available by the commission
to others upon request.
(e) The decision of the review agency shall be considered the
final decision of the board authority; however, the review agency
may remand the matter to the board authority for further action or
consideration.
(f) Upon the entry of a final decision by the review agency,
any affected party may within thirty days after the date upon which
all affected parties receive notice of the decision of the review
agency, appeal said decision in the circuit court of Kanawha
County. The decision of the review agency shall be reviewed by
that circuit court in accordance with the provisions for the
judicial review of administrative decisions contained in section
four, article five, chapter twenty-nine-a of this code.
§16-29B-14. Injunction; mandamus.
The board Executive Director may compel obedience to its lawful orders by injunction or mandamus or other proper proceedings
in the name of the state in any circuit court having jurisdiction
of the parties or of the subject matter, or the Supreme Court of
Appeals direct, and such proceeding shall be determined in an
expeditious manner.
§16-29B-15. Refusal to comply.
(a) Whenever a hospital fails or refuses to furnish to the
Executive Director or the board any records or information
requested under the provisions of this article or otherwise fails
or refuses to comply with the requirements of this article or any
reasonable legislative or procedural rule and regulation
promulgated by the board authority under the provisions of this
article, the board as the adjudicatory arm of the authority may
make and enter an order of enforcement and serve a copy thereof on
the hospital in question by certified mail, return receipt
requested.
(b) The hospital shall be granted a hearing on the order of
enforcement if, within twenty days after receipt of a copy thereof,
it files with the board authority a written demand for hearing. A
demand for hearing shall operate automatically to stay or suspend
the execution of the order of enforcement, with the exception of
orders relating to rate increases.
(c) Upon receipt of a written demand for a hearing, the board
authority shall set a time and place therefor, not less than ten
and no more than thirty days thereafter. Any scheduled hearing may be continued by the board upon motion for good cause shown by the
hospital demanding the hearing.
§16-29B-17. Uniform system of financial reporting.
(a) The Executive Director with advice of the board shall
develop and specify a uniform system of reporting utilization,
accounting and financial reporting, including cost allocation
methods by which hospitals shall record their revenues, income,
expenses, capital outlays, assets, liabilities and units of
service. The development and specification process aforementioned
shall be conducted in a manner determined by the Executive Director
with advice of the board to be most efficient for that purpose
notwithstanding the provisions of chapter twenty-nine-a of this
code. Each hospital shall adopt this uniform system for the
purpose of reporting utilization, costs and revenues to the board
authority effective for the fiscal year beginning on or after
twelve months from the effective date of this article.
(b) The board authority may provide for modification in the
accounting and reporting system in order to correctly reflect
differences in the scope or type of services and financial
structures of the various categories, sizes and types of hospitals
and in a manner consistent with the purposes of this article.
(c) The board authority may provide technical assistance to
those hospitals which request it and which evidence sufficient need
for assistance in the establishment of a data collection system to
the extent that funds are available to the board authority for this purpose.
(d) The board authority shall, after consultation with health
care providers, purchasers, classes of purchasers and third-party
payors, adopt a mandatory form for reporting to the board
authority, at its request, medical diagnosis, treatment and other
services rendered to each purchaser by health care providers
subject to the provisions of this article.
(e) Following a public hearing, the board authority shall
establish a program to minimize the administrative burden on
hospitals by eliminating unnecessary duplication of financial and
operational reports; and to the extent possible, notwithstanding
any other law, coordinate reviews, reports and inspections
performed by federal, state, local and private agencies.
§16-29B-18. Annual reporting.
(a) It shall be the duty of every health care provider which
comes under the jurisdiction of this article and article five-f of
this chapter to file with the board authority the reports required
by such article five-f and the following financial statements or
reports in a form and at intervals specified by the board
authority, but at least annually:
(1) A balance sheet detailing the assets, liabilities and net
worth of the hospital for its preceding fiscal year;
(2) A statement of income and expenses for the preceding
fiscal year;
(3) A statement of services rendered and services available; and
(4) Such other reports as the board authority may prescribe.
Where more than one licensed hospital is operated by the
reporting organization, the information required by this section
shall be reported for each hospital separately.
(b) It shall be the duty of every related organization to file
with the board authority, within thirty days from the effective
date of this section, the following financial statements or reports
for each of its three prior fiscal years:
(1) A balance sheet detailing the assets, liabilities and net
worth of the related organization;
(2) A statement of income and expenses;
(3) A statement of cash flows; and
(4) Such other information as the board authority may
prescribe.
After the initial filing of the financial information required
by this subsection, every related organization shall thereafter
file annual financial reports with the board authority in a form
specified by the board authority.
(c) The annual financial statements filed pursuant to this
section shall be prepared in accordance with the system of
accounting and reporting adopted under section seventeen of this
article. The board authority may require attestations from
responsible officials of the hospitals or related organizations
that such reports have to the best of their knowledge been prepared truthfully and in accordance with the prescribed system of
accounting and reporting.
(d) All reports filed under any provisions of this article,
except personal medical information personally identifiable to a
purchaser and any tax return, shall be open to public inspection
and shall be available for examination at the offices of the board
authority during regular business hours.
(e) Whenever a further investigation is deemed necessary or
desirable to verify the accuracy of any information set forth in
any statement, schedule or report filed by a health care provider
or related organization under the provisions of this section, the
board authority may require a full or partial audit of the records
of the health care provider or related organization.
§16-29B-19a. Additional legislative directives; studies, findings
and recommendations.
(a) The Legislature finds and declares that changing market
forces require periodic changes in the regulatory structure for
health care providers and hereby directs the board Executive
Director or his or her designee to study the following:
(1) The certificate of need program, including the effect of
any changes on managed care and access for uninsured and rural
consumers; determining which services or capital expenditures
should be exempt and why; and the status of similar programs in
other states; is there a means to accommodate concerns of health
care providers and hospitals situate in West Virginia which border states that do not have a certificate of need programs; and whether
there exists a benefit to discontinuing the certificate of need
program in its entirety. The results of the study should be
presented to the Legislative Oversight Commission on Health and
Human Resources Accountability by December 1, 2010;
(2) The hospital rate-setting methodology, including the need
for hospital rate-setting and the development of alternatives to
the cost-based reimbursement methodology;
(3) (2) Managed care markets, including the need for
regulatory programs in managed care markets; and
(4) (3) Barriers or obstacles, if any, presented by the
certificate of need program or standards in the state health plan
to health care providers' need to reduce excess capacity,
restructure services and integrate the delivery of services.
(b) The Executive Director may consult with the board and may
form task forces to assist it in addressing these issues. and it
The Executive Director or his or her designee shall prepare a
report on its his or her findings and recommendations, which is to
be filed with the Governor, the President of the Senate and the
Speaker of the House of Delegates on or before the first day of
October, one thousand nine hundred ninety-eight December 1, 2010,
identifying each problem and recommendation with specificity and
the effect of each recommendation on cost, access and quality of
care. The task forces, if formed, shall be composed of
representatives of consumers, businesses, providers, payors and state agencies.
(c) The board Executive Director shall report quarterly to the
Legislative Oversight Commission on Health and Human Resources
Accountability regarding the appointment, direction and progress of
the studies.
§16-29B-23. Utilization review and quality assurance; quality
assurance advisory group.
(a) In order to avoid unnecessary or inappropriate utilization
of health care services and to ensure high quality health care, the
board authority shall establish a utilization review and quality
assurance program. The board authority shall coordinate this
program with utilization review and peer review programs presently
established in state agencies, hospital services and health service
corporations, hospitals or other organizations.
(b) With the assistance of the above-mentioned entities, and
after public hearings, the board authority shall develop a plan for
the review, on a sampling basis, of the necessity of admissions,
length of stay and quality of care rendered at said hospitals.
(c) The board authority shall monitor identified problem areas
and shall impose such sanctions and provide such incentives as
necessary to ensure high quality and appropriate services and
utilization in hospitals under the jurisdiction of this article.
(d) To assist the board authority in its efforts under this
section, the board Executive Director shall create a quality
assurance advisory group and appoint one of the board's members as chairman of the group. The group shall be composed of
representatives of consumers, providers, payors and regulating
agencies.
§16-29B-24. Powers with respect to insurance policies and health
organizations.
(a) With respect to any policy of accident or health
insurance, including, but not limited to, those insurance policies
covered by articles fifteen, sixteen and sixteen-a, chapter
thirty-three of this code, and with respect to any health service,
care or maintenance organization, or similar health-related
organizations, including, but not limited to, those covered by
articles twenty-four, twenty-five and twenty-five-a, chapter
thirty-three of this code, the
board authority
shall:
(1) Be considered for all purposes a directly affected party
before the Insurance Commissioner for purposes of any application,
hearing or appeal on insurance matters;
(2) Review requests for, and make comments on, proposed rate
increases or coverage decreases submitted to the Insurance
Commissioner with respect to the reasonableness of the request and
impact on health care cost containment;
(3) Comment on the advisability, reasonableness and impact on
health care cost containment of any other matter coming before the
Insurance Commissioner or any other governmental agency or body.
(b) On or before the date of filing with the Insurance
Commissioner of any rate, including any proposed increase or decrease thereof, and any coverage matter, including any proposed
increase or decrease thereof, each company or organization,
described in subsection (a) above, shall notify the
board authority
of such filing, by copy thereof or notice form, as the
board
authority
directs.
(c) Each company or organization, described in subsection (a)
above, shall establish, in a written report which shall be
incorporated into each proposed rate application, that it has
thoroughly investigated and considered:
(1) The economic and social impact of any proposed rate
increase, or coverage decrease, on health care cost containment and
upon health care purchasers, including classes of purchasers, such
as the elderly and low and fixed income persons;
(2) State-of-the-art advances in insurance and health care
management and rate design as alternatives to or in mitigation of
any rate increase, or coverage decrease, which report shall
describe the state-of-the-art advances considered and shall contain
specific findings as to each consideration, including the reasons
for adoption or rejection of each:
(3) Implementation of cost control systems, including a
combination of education, persuasion, financial incentives and
disincentives to control costs;
(4) Initiatives to create alternative delivery systems; and
(5) Efforts to encourage health care providers to control
costs, including the elimination of unnecessary or duplicative facilities and services, promotion of alternative forms of care,
and other cost control mechanisms.
§16-29B-25. Public disclosure.
From time to time, the board authority shall engage in or
carry out analyses and studies relating to health care costs, the
financial status of any health care provider subject to the
provisions of this article or any other appropriate related
matters, and it shall be empowered to publish and disseminate any
information which would be useful to members of the general public
in making informed choices about health care providers.
§16-29B-26. Exemptions from state antitrust laws.
Actions of the board authority shall be exempt from antitrust
action as provided in section five, article eighteen, chapter
forty-seven of this code. Any actions of health care providers
under the board's authority's jurisdiction, when made in compliance
with orders, directives, rules or regulations issued or promulgated
by the board authority, shall likewise be exempt. Health care
providers shall be subject to the antitrust guidelines of the
federal trade commission and the department of justice.
§16-29B-28. Continuation of the Health Care Authority.
Pursuant to the provisions of article ten, chapter four of
this code, the Health Care Authority shall continue to exist until
July 1, eight 2012, unless sooner terminated, continued or
reestablished.
ARTICLE 29G. WEST VIRGINIA HEALTH INFORMATION NETWORK.
§16-29G-2. Creation of West Virginia Health Information Network
board of directors; powers of the board of
directors.
(a) The network is created under the Health Care Authority for
administrative, personnel and technical support purposes. The
network shall be managed and operated by a board of directors. The
board of directors is an independent, self-sustaining board with
the powers specified in this article.
(b) The board is part-time. Each member shall devote the time
necessary to carry out the duties and obligations of members on the
board.
(c) Members appointed by the Governor may pursue and engage in
another business or occupation or gainful employment that is not in
conflict with his or her duties as a member of the board.
(d) The board shall meet at such times as the chair may
decide. Eight members of the board are a quorum for the purposes
of the transaction of business and for the performance of any duty.
(e) A majority vote of the members present is required for any
final determination by the board. Voting by proxy is not allowed.
(f) The Governor may remove any board member for incompetence,
misconduct, gross immorality, misfeasance, malfeasance or
nonfeasance in office.
(g) The board shall consist of seventeen members, designated
as follows:
(1) The Dean of the West Virginia University School of Medicine or his or her designee;
(2) The Dean of the Marshall University John C. Edwards School
of Medicine or his or her designee;
(3) The President of the West Virginia School of Osteopathic
Medicine or his or her designee;
(4) The Secretary of the Department of Health and Human
Resources or his or her designee;
(5) The President of the West Virginia Board of Pharmacy or
his or her designee;
(6) The Director of the Public Employees Insurance Agency or
his or her designee;
(7) The Chief Technology Officer of the Office of Technology
or his or her designee;
(8) The Chair of the Health Care Authority or his or her
designee;
(9) The President of the West Virginia Hospital Association or
his or her designee;
(10) The President of the West Virginia State Medical
Association or his or her designee;
(11) The Chief Executive Officer of the West Virginia Health
Care Association or his or her designee;
(12) The Executive Director of the West Virginia Primary Care
Association or his or her designee; and
(13) Five public members that serve at the will and pleasure
of the Governor and are appointed by the Governor with advice and consent of the Senate as follows:
(i) One member with legal expertise in matters concerning the
privacy and security of health care information;
(ii) Two physicians actively engaged in the practice of
medicine in the state;
(iii) One member engaged in the business of health insurance
who is employed by a company that has its headquarters in West
Virginia; and
(iv) The chief executive officer of a West Virginia
corporation working with West Virginia health care providers,
insurers, businesses and government to facilitate the use of
information technology to improve the quality, efficiency and
safety of health care for West Virginians.
(h) The Governor shall appoint one of the board members to
serve as chair of the board at the Governor's will and pleasure.
The board shall annually select one of its members to serve as vice
chair. The Chair Executive Director of the Health Care Authority
shall serve as the secretary-treasurer of the board.
(i) The public members of the board shall serve a term of four
years and may serve two consecutive terms. At the end of a term,
a member of the board shall continue to serve until a successor is
appointed. Those members designated in subdivisions (1) through
(12), inclusive, subsection (g) of this section shall serve on the
board only while holding the position that entitle them to
membership on the board.
(j) The board may propose the adoption or amendment of rules
to the Health Care Authority to carry out the objectives of this
article.
(k) The board may appoint committees or subcommittees to
investigate and make recommendations to the full board. Members of
such committees or subcommittees need not be members of the board.
(l) Each member of the board and the board's committees and
subcommittees is entitled to be reimbursed for actual and necessary
expenses incurred for each day or portion thereof engaged in the
discharge of official duties in a manner consistent with guidelines
of the Travel Management Office of the Department of
Administration.
§16-29G-4. Creation of the West Virginia Health Information
Network account; authorization of Health Care
Authority to expend funds to support the network.
(a) All moneys collected shall be deposited in a special
revenue account in the State Treasury known as the West Virginia
Health Information Network Account. Expenditures from the fund
shall be for the purposes set forth in this article and are not
authorized from collections but are to be made only in accordance
with appropriation by the Legislature and in accordance with the
provisions of article three, chapter twelve of this code and upon
fulfillment of the provisions of article two, chapter eleven-b of
this code: Provided, That for the fiscal year ending June 30,
2007, expenditures are authorized from collections rather than pursuant to appropriations by the Legislature.
(b) Consistent with section eight, article twenty-nine-b of
this chapter, the Health Care Authority's provision of
administrative, personnel, technical and other forms of support to
the network is necessary to support the activities of the Health
Care Authority board and constitutes a legitimate, lawful purpose
of the Health Care Authority. board Therefore, the Health Care
Authority is hereby authorized to expend funds from its Health Care
Cost Review Fund, established under section eight, article
twenty-nine-b of this chapter, to support the network's
administrative, personnel and technical needs and any other network
activities the Health Care Authority deems necessary.
§16-29G-5. Immunity from suit; limitation of liability.
The network is not a health care provider and is not subject
to claims under article seven-b, chapter fifty-five of this code.
No person who participates or subscribes to the services or
information provided by the network is liable in any action for
damages or costs of any nature, in law or equity, which result
solely from that person's use or failure to use network information
or data that was imputed or retrieved in accordance with the Health
Insurance Portability and Accountability Act of 1996 and any
amendments and regulations under the act, state confidentiality
laws and the rules of the network as approved by the Executive
Director of the Health Care Authority. In addition, no person is
subject to antitrust or unfair competition liability based on membership or participation in the network, which provides an
essential governmental function for the public health and safety
and enjoys state action immunity.
§16-29G-6. Property rights.
(a) All persons providing information and data to the network
shall retain a property right in that information or data, but
grant to the other participants or subscribers a nonexclusive
license to retrieve and use that information or data in accordance
with the Health Insurance Portability and Accountability Act of
1996 and any amendments and regulations under the act, state
confidentiality laws and the legislative rules proposed by the
Health Care Authority.
(b) All processes or software developed, designed or purchased
by the network shall remain its property subject to use by
participants or subscribers in accordance with the rules or
regulations proposed by the Health Care Authority.
ARTICLE 29I. WEST VIRGINIA HEALTH CARE AUTHORITY REVOLVING LOAN
AND GRANT FUND.
§16-29I-4. Revolving fund created.
(a) (1) The board authority shall create and establish a
special revolving fund of moneys made available to the fund by
appropriation, grant, contribution, loan, or statutory dedication
to be known as the West Virginia Health Care Authority Revolving
Loan Fund. The fund shall be governed, administered and accounted
for by the board Executive Director or his or her designee.
(2) Any money collected pursuant to this section, including
the repayment of loans made by the board authority, shall be paid
into the fund by any state agent or entity charged with the
collection of the money, credited to the fund, and used only for
the purposes set forth in this article.
(b) The board authority may pledge revenues to the fund and
from time to time establish one or more restricted accounts within
the fund for the purpose of providing funds to guarantee loans made
pursuant to this article. No loan guarantee shall be made pursuant
to this article unless recourse under the loan guarantee is limited
solely to amounts in the restricted account or accounts. No person
shall have any recourse to any restricted accounts established
pursuant to this subsection other than those persons to whom the
loan guarantee or loan guarantees have been made.
(c) Each loan or loan guarantee made or provided by the board
authority from the fund shall be evidenced by a loan document, a
loan guarantee document or any other writing or document or
documents as the board authority may consider appropriate, between
the Health Care Authority Board and the hospital or hospitals to
which the loan, or loan guarantee, was made available or provided.
The agreements shall include, without limitation and to the extent
applicable, the following provisions:
(1) The estimated total costs of the hospital restructuring
plan, the amount of the loan, or loan guarantee and the terms of
repayment and the security for the loan if any;
(2) The specific purposes for which the loan proceeds shall be
expended and the conditions and procedures for dispersing a loan
proceeds; and
(3) The duties, conditions and obligations imposed by the
board authority upon the hospital or hospitals regarding the
hospital restructuring plan.
(d) Moneys in the fund shall be approved for expenditure by
the Health Care Authority Board only as the moneys are available in
the fund. Approval of expenditures by the board authority may
occur without appropriation by the Legislature prior to July 1,
2008. After July 1, 2008, expenditures from the fund shall be made
by the board authority only pursuant to available amounts
appropriated by the Legislature.
CHAPTER 33. INSURANCE.
ARTICLE 15B. UNIFORM HEALTH CARE ADMINISTRATION ACT.
§33-15B-3. Health care authority to promulgate rules; use of
standardized forms and classifications; advisory
group.
(a) The West Virginia Health Care Authority shall promulgate
legislative rules in accordance with the provisions of chapter
twenty-nine-a of this code regarding the implementation and use of
uniform health care administrative forms. Such rules shall
establish, where practicable, the acceptance and use throughout the
health care system of standard administrative forms, terms or
procedures, including, but not limited to, the following:
(1) The standard health care financing administration fifteen
hundred (HCFA 1500) health insurance claim form, as amended, or
other similar forms, terms, and definitions to be used which are
consistent with health care and insurance industry standards.
(2) International classification of disease, ninth clinical
modifications (ICD-9-CM) and common procedural terminology (CPT)
codes, as amended, or other similar forms, terms, and definitions
to be used which are consistent with health care and insurance
industry standards.
(3)National uniform billing data element specifications (UB-
92), as amended, and as supplemented by the West Virginia uniform
billing committee, or other similar forms, terms, and definitions
to be used which are consistent with health care and insurance
industry standards.
(4) Consideration of current practices involving reimbursement
of claims and explanation of benefits, and the implementation of
standards and guidelines regarding explanation of benefits,
including, but not limited to, consideration of line item
explanations of payments or denial of payments.
(b) The legislative rules required herein shall be developed
by the West Virginia Health Care Authority with the advice of an
advisory group to be appointed by the board Executive Director of
the West Virginia Health Care Authority. Such advisory group shall
consist of representatives of consumers, providers, payors, and
regulatory agencies, including representatives from the following: The office of the Insurance Commissioner; the West Virginia Health
Care Authority; West Virginia Dental Association; West Virginia
Pharmacists Association; the West Virginia Hospital Association;
commercial health insurers; third party administrators; the West
Virginia State Medical Association; the West Virginia Nurses
Association; Public Employees Insurance Agency; Workers'
Compensation Commission; and consumers. The West Virginia Health
Care Authority shall form such advisory group after the effective
date of this section.
(c) The West Virginia Health Care Authority and the advisory
group shall review the legislative rules effected pursuant to this
section as necessary and update the same in a timely manner in
order to conform to current legislation and health care and
insurance industry standards and trends.
NOTE: The purpose of this bill is to create the position of
Executive Director of the Health Care Authority to act as the
administrative head of the agency; to change the number and make-up
of the board of directors and to clarify their powers and duties;
to require that the members of the board of the West Virginia
Health Care Authority be employed on a part time basis and that the
compensation for board members be set in statute; to eliminate rate
review from the Health Care Authority powers and duties.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
§16-29B-5a
is new; therefore, strike-throughs and underscoring
have been omitted.
§16-29B-19, §16-29B-20, §16-29B-21 and §16-29B-21a
have been
repealed.