The Global Budget Revenue (GBR) methodology implemented by the Commission effective January 1, 2014, establishes reasonable revenue levels for Maryland's general acute hospitals, which will enable them to improve quality and efficiency on a solvent basis within the constraints imposed by the All-Payer Model. In setting reasonable revenue levels, the Commission shall take into account a number of factors. These may include, but are not limited to the following: The casemix severity and reasonable utilization of the hospital’s patients; The historical charges of the hospital; The statutory requirement regarding the reasonable relationship between costs and charges; The hospital’s payer mix; The reasonable uncompensated care requirements of the hospital; The reasonable Graduate Medical Education (GME) costs of the hospital as determined by the Commission; Appropriate adjustments, if any, associated with exceptional or outlier cases as defined by the Commission; Wage levels at the hospital and at other hospitals in the geographic area of the hospital and elsewhere in Maryland; Adjustments for quality improvement and value-based payment programs applicable to the hospital; Reasonable infrastructure funding for care management and care coordination for hospital patients; The annual update factor; The proportion of unnecessary care, including Potentially Avoidable Utilization (PAU) at the hospital; and The performance of the State as a whole under the All-Payer Model. The GBR shall be implemented through a written agreement entered into by the Commission and each individual general acute hospital. This agreement and any addenda thereto, which shall be annual and renewed automatically, shall set forth all relevant provisions governing the GBR including, but not limited to, performance corridors; interim rate adjustments; the exclusion or special treatment of certain cases; the treatment of volume changes, including those involving residents of Maryland and other patients; the penalties associated with failure to comply with the terms of the GBR agreement; interim revenue limits; care redesign requirements; and other changes to the agreement that may be needed from time to time. A hospital that enters into a GBR agreement shall submit a signed copy of the agreement to the Commission’s offices within 60 days after it is initially approved by the Commission. A hospital that is party to the addendum shall submit a signed copy of the addendum to the Commission’s offices within 60 days from the issuance of the addendum. Failure to submit the signed GBR agreement or the signed addendum in a timely manner, absent an extension granted by staff, may subject the hospital to penalties under COMAR 10.37.01.03R. Thereafter, on an annual basis, the hospital shall receive an updated rate order. A hospital that disagrees with a proposed GBR may file a full rate application with the Commission in accordance with Regulation .03 of this chapter.