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