ENROLLED
COMMITTEE SUBSTITUTE
FOR
Senate Bill No. 458
(By Senators Tomblin, Mr. President, and Buckalew,
By Request of the Executive)
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[Passed April 12, 1997; in effect ninety days from passage.]
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AN ACT to repeal section sixteen, article twenty-nine-b, chapter
sixteen of the code of West Virginia, one thousand nine
hundred thirty-one, as amended; to amend and reenact
sections one, two, three, five, eight, nine, eleven,
seventeen, eighteen, nineteen, nineteen-a, twenty, twenty- three, twenty-five, twenty-six, twenty-seven and twenty- eight of said article; and to further amend said article by
adding thereto a new section, designated section six, all
relating to the West Virginia health care authority;
including additional legislative findings and purpose;
changing the agency's title; amending and adding certain
definitions; amending conflicting employment prohibition for
board members and former board members to comply with the governmental ethics act; deleting the review council;
authorizing information gathering and coordination; creating
a data advisory group and expanding the board's powers
generally; changing annual reporting requirements; related
programs and priorities; including utilization reporting
with uniform system of accounts and financing; defining
entities subject to annual reporting requirements; requiring
review and reporting for alternatives to present rate- setting; legislative directives, studies, findings and
recommendations; explaining discount and risk-bearing
contract review and authorizing promulgation of rules;
creating a quality assurance advisory group; modifying
public disclosure, exemptions from state antitrust laws and
penalties for violations to include health care providers;
and extending termination date.
Be it enacted by the Legislature of West Virginia:
That section sixteen, article twenty-nine-b, chapter sixteen
of the code of West Virginia, one thousand nine hundred thirty- one, as amended, be repealed; and that sections one, two, three,
five, eight, nine, eleven, seventeen, eighteen, nineteen,
nineteen-a, twenty, twenty-three, twenty-five, twenty-six,
twenty-seven and twenty-eight of said article be amended and
reenacted; and that said article be further amended by adding thereto a new section, designated section six, all to read as
follows:
ARTICLE 29B. HEALTH CARE AUTHORITY.
§16-29B-1. Legislative findings; purpose.
The Legislature hereby finds and declares that the health
and welfare of the citizens of this state is being threatened by
unreasonable increases in the cost of health care services, a
fragmented system of health care, lack of integration and
coordination of health care services, unequal access to primary
and preventative care, lack of a comprehensive and coordinated
health information system to gather and disseminate data to
promote the availability of cost-effective, high-quality services
and to permit effective health planning and analysis of
utilization, clinical outcomes and cost and risk factors. In
order to alleviate these threats: (1) Information on health care
costs must be gathered; (2) a system of cost control must be
developed; and (3) an entity of state government must be given
authority to ensure the containment of health care costs, to
gather and disseminate health care information; to analyze and
report on changes in the health care delivery system as a result
of evolving market forces, including the implementation of
managed care; and to assure that the state health plan,
certificate of need program, rate regulation program and information systems serve to promote cost containment, access to
care, quality of services and prevention. Therefore, the purpose
of this article is to protect the health and well-being of the
citizens of this state by guarding against unreasonable loss of
economic resources as well as to ensure the continuation of
appropriate access to cost-effective, high-quality health care
services.
§16-29B-2. Short title.
This article may be cited as the "West Virginia 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) "Charges" means the economic value established for
accounting purposes of the goods and services a hospital provides
for all classes of purchasers;
(b) "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;
(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;
(d) "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) "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) "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) "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) "Rates" means all value given or money payable to health
care providers for health care services, including fees, charges
and cost reimbursements;
(i) "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;
(j) "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; appointment of chairman, and
meetings of the board.
The "West Virginia Health Care Cost Review Authority",
heretofore created as an autonomous division of the department of
health, is hereby continued as an autonomous division of the
department of health and human resources and shall be known as
the "West Virginia Health Care Authority", hereinafter referred
to as the board. Any references in this code to the West
Virginia health care cost review authority shall mean the West
Virginia health care authority.
(a) The board shall consist of three members, appointed by
the governor, with the advice and consent of the Senate. The board members shall be citizens and residents of this state. No
more than two of said 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 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. 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. The
governor shall appoint three board members, one for a term of two
years, one for a term of four years and one for a term of six
years, with all the terms beginning on the twelfth day of March,
one thousand nine hundred eighty-three. All future appointments
shall be for terms of six years, except that an appointment to
fill a vacancy shall be for the unexpired term only.
(c) 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 therein, may serve as a member of the board or
as an employee thereof. Nor may any such board member be a
candidate for or hold public office or be a member of any
political committee while acting as such board member; nor may
any board member or employee of said board receive anything of
value, either directly or indirectly, from any third-party payor
or health care provider. Should any of the board members become
a candidate for any public office or for membership on any
political committee, the governor shall remove said 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 such act shall not apply to employment accepted
after termination of the board.
(d) The concurrent judgment of two of the board members when
in session as the board shall be deemed 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.
(e) In order to adequately compensate the chairman of the
board and other members of the board for additional duties newly
imposed by law and not heretofore required by law, the annual
salary of the chairman of the board shall be sixty-five thousand
dollars and the annual salary of the other board members shall be
sixty thousand dollars.
§16-29B-6. Information gathering and coordination; data advisory
group.
(a) 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 data base
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 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 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, and shall develop a comprehensive system to
collect ambulatory health care data. The board is authorized to
gain access to any health-related data base in state government
for the purposes of fulfilling its duties:
Provided, That for
any data base to which the board gains access, the use and
dissemination of information from the data base shall be subject
to the confidentiality provisions applicable to such data base.
(b) To advise the board in its efforts under this section,
the board shall create a data advisory group and appoint one of
the board's members as chair of the group. The group shall be
composed of representatives of consumers, businesses, providers,
payors and state agencies. The data advisory group shall assist
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 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 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 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
finds relevant and directs staff to investigate. The board 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 funds for sums necessary to carry out its
responsibilities and for reasonable travel expenses to attend
meetings.
§16-29B-8. Powers generally; budget expenses of the board.
(a) In addition to the powers granted to the board elsewhere
in this article, the board may:
(1) Adopt, amend and repeal necessary, appropriate and
lawful policy guidelines and rules in accordance with article
three, chapter twenty-nine-a of this code:
Provided, That
subsequent amendments and modifications to any 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 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,
and shall in no respect inure to the private benefit of 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 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
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 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 board and its staff.
(c) Each hospital subject to the provisions of this article
shall be assessed by 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 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 the first
day of July 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.
(e) The board 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 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 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-11. Related programs.
In addition to carrying out its duties under this article,
the board 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 shall be guided by
the state health plan approved by the governor.
§16-29B-17. Uniform system of financial reporting.
(a) 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 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 effective for the fiscal year beginning on or after twelve
months from the effective date of this article.
(b) The board 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 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 for this
purpose.
(d) The board shall, after consultation with health care
providers, purchasers, classes of purchasers and third-party
payors, adopt a mandatory form for reporting to the board, 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 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 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, 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 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, 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 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 in a form
specified by the board.
(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 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 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 may require a full or partial audit of the records of the
health care provider or related organization.
§16-29B-19. Rate-setting powers generally.
(a) The board shall have power: (1) To initiate reviews and
investigations of hospital rates and establish and approve such
rates; (2) to initiate reviews and investigations of hospital
rates for specific services and the component factors which
determine such rates; (3) to initiate reviews and investigations
of hospital budgets and the specific components of such budgets;
and (4) to approve or disapprove hospital rates and budgets
taking into consideration the criteria set forth in section twenty of this article.
(b) In the interest of promoting the most efficient and
effective use of hospital service, the board may adopt and
approve alternative methods of rate determination. The board may
also adopt methods of charges and payments of an experimental
nature which are in the public interest and consistent with the
purpose of this article.
(c) The board shall examine the need for an alternative to
the current rate-setting method as a means of controlling
hospital costs and submit the findings, recommendations and any
proposed drafts of legislation, if necessary, in a report to the
legislative oversight commission on health and human resources
accountability and the governor on or before the first day of
August, one thousand nine hundred ninety-eight.
§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 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;
(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) Managed care markets, including the need for regulatory
programs in managed care markets; and
(4) 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 board may form task forces to assist it in
addressing these issues and it shall prepare a report on its
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, 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 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-20. Rate determination.
(a) Upon commencement of review activities, no rates may be
approved by the board nor payment be made for services provided
by hospitals under the jurisdiction of the board by any purchaser
or third-party payor to or on behalf of any purchaser or class of
purchasers unless:
(1) The costs of the hospital's services are reasonably
related to the services provided and the rates are reasonably
related to the costs;
(2) The rates are equitably established among all purchasers
or classes of purchasers within a hospital without discrimination
unless federal or state statutes or rules and regulations
conflict with this requirement. On and after the effective date
of this section, a summary of every proposed contract, or
amendment to any existing contract, for the payment of patient
care services between a purchaser or third-party payor and a
hospital shall be filed by the hospital for review by the board,
which reviews shall occur no less frequently than each calendar
quarter: (A) If the contract establishes a discount to the
purchaser or third-party payor, it shall not take effect until
approved by the board. For purposes of this article, a risk- bearing contract is reviewable as a discount contract and the
amount computed as the discount percentage by the provider on the board shall be the approved amount of the discount. The
difference, if any, between the actual discount percentage and
amount and the approved amount, shall not be considered for rate- setting purposes; (B) the board may promulgate rules, in
accordance with the provisions of section eight of this article,
that establish the criteria for review of discount contracts,
which shall include that: (i) No discount shall be approved by
the board which constitutes an amount below the cost to the
hospital; (ii) the cost of any discount contained in the contract
will not be shifted to any other purchaser or third-party payor;
(iii) the discount will not result in a decrease in the
hospital's average number of medicare, medicaid or uncompensated
care patients served during the previous three fiscal years; and
(iv) the discount is based upon criteria which constitutes a
quantifiable economic benefit to the hospital. The board may
define by rule what constitutes "cost" in subparagraphs (i) and
(ii) of this paragraph; "purchaser" in subparagraph (iii) of this
paragraph; and "economic benefit" in subparagraph (iv) of this
paragraph. Any rules promulgated pursuant to this subsection may
be filed as emergency rules. All information submitted to the
board shall be certified by the hospital's chief executive
officer and chief financial officer as to its accuracy and
truthfulness;
(3) The rates of payment for medicaid are reasonable and adequate to meet the costs which must be incurred by efficiently
and economically operated hospitals subject to the provisions of
this article. The rates shall take into account the situation of
hospitals which serve disproportionate numbers of low income
patients and assure that individuals eligible for medicaid have
reasonable access, taking into account geographic location and
reasonable travel time, to inpatient hospital services of
adequate quality;
(4) The rates are equitable in comparison to prevailing
rates for similar services in similar hospitals as determined by
the board; and
(5) In no event shall a hospital's receipt of emergency
disaster funds from the federal government be included in the
hospital's gross revenues for either rate-setting or assessment
purposes.
(b) In the interest of promoting efficient and appropriate
utilization of hospital services, the board shall review and make
findings on the appropriateness of projected gross revenues for
a hospital as the revenues relate to charges for services and
anticipated incidence of service.
(c) When applying the criteria set forth in subsections (a)
and (b) of this section, the board shall consider all relevant
factors, including, but not limited to, the following: The
economic factors in the hospital's area; the hospital's efforts to share services; the hospital's efforts to employ less costly
alternatives for delivering substantially similar services or
producing substantially similar or better results in terms of the
health status of those served; the efficiency of the hospital as
to cost and delivery of health care; the quality of care;
occupancy level; a fair return on invested capital, not otherwise
compensated for; whether the hospital is operated for profit or
not for profit; costs of education; and income from any
investments and assets not associated with patient care,
including, but not limited to, parking garages, residences,
office buildings, and income from related organizations and
restricted funds whether or not associated with patient care.
(d) Wages, salaries and benefits paid to or on behalf of
nonsupervisory employees of hospitals subject to this article are
not subject to review unless the board first determines that the
wages, salaries and benefits may be unreasonably or uncustomarily
high or low. This exemption does not apply to accounting and
reporting requirements contained in this article, nor to any that
may be established by the board. The term "nonsupervisory
personnel", for the purposes of this section, means, but is not
limited to, employees of hospitals subject to the provisions of
this article who are paid on an hourly basis.
(e) Reimbursement of capital and operating costs for new
services and capital projects subject to article two-d of this chapter shall not be allowed by the board if the costs were
incurred subsequent to the eighth day of July, one thousand nine
hundred seventy-seven, unless they were exempt from review or
approved: (i) By the state health planning and development
agency prior to the first day of July, one thousand nine hundred
eighty-four; or (ii) thereafter, pursuant to the provisions of
article two-d of this chapter.
(f) The board shall consult with relevant licensing agencies
and may require them to provide written findings with regard to
their statutory functions and information obtained by them in the
pursuit of those functions. Any licensing agency empowered to
suggest or mandate changes in buildings or operations of
hospitals shall give notice to the board together with any
findings.
(g) A hospital shall file a complete rate application with
the board on an annual basis a minimum of seventy-five days prior
to the beginning of its fiscal year. If the application is filed
and determined to be complete by the board sixty days prior to
the beginning of the hospital's fiscal year, and no hearing is
requested on the application, the board shall set the rates in
advance of the year during which they apply and shall not adjust
the rates for costs actually incurred:
Provided, That if the
board does not establish rates by the beginning of the hospital's fiscal year, and a hearing has not been requested, the board
shall establish rates retroactively to the beginning of the
hospital's fiscal year:
Provided, however, That if the board
does not establish rates by the beginning of the hospital's
fiscal year, and a hearing has been requested, the board may
establish rates retroactively to the beginning of the fiscal
year. This subsection shall not apply to the procedure set forth
in subsection (c), section twenty-one of this article.
(h) No hospital may charge for services at rates in excess
of those established in accordance with the requirements of and
procedures set forth in this article.
(i) Notwithstanding any other provision of this article, the
board shall approve all requests for rate increases by hospitals
which are licensed for one hundred beds or less and which are not
located in a standard metropolitan statistical area where the
rate of increase is equal to or less than the lowest rate of
inflation as established by a recognized inflation index for
either the national or regional hospital industry. The board
may, by rule, impose reporting requirements to ensure that a
hospital does not exceed the rate of increases permitted in this
section.
(j) Notwithstanding any other provision of this article, the
board shall develop an expedited review process applicable to all hospitals licensed for more than one hundred beds or that are
located in a standard metropolitan statistical area for rate
increase requests which may be based upon a recognized inflation
index for the national or regional hospital industry.
(k) The board may require hospitals to file such additional
information as it deems necessary to evaluate a market-driven
system of rate setting.
§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 shall establish a utilization review and
quality assurance program. The board 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 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 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 in its efforts under this section,
the board 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-25. Public disclosure.
From time to time, the board 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 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 jurisdiction, when made in compliance with orders,
directives, rules or regulations issued or promulgated by the
board, 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-27. Penalties for violations.
In addition to civil remedies set forth, any person or
health care provider violating any provision of this article or
any valid order or rule lawfully established hereunder shall be
guilty of a misdemeanor and, upon conviction thereof, shall be
punished by a fine of not more than one thousand dollars. Each
day of a continuing violation after conviction shall be
considered a separate offense. No fines assessed may be
considered part of the hospital's costs in the regulation of its
rates.
§16-29B-28. Termination date.
Pursuant to the provisions of section four, article ten,
chapter four of this code, the health care authority shall
continue to exist until the first day of July, one thousand nine
hundred ninety-nine, to allow for a completion of an audit by the
joint committee on government operations.