“Burden of proof” means the burden of persuasion by the preponderance of the evidence. “Commission” means the Health Services Cost Review Commission. “Executive Director” means the Executive Director of the Commission, or in his absence, the Commission staff member designated to act in his stead. “Opinion” means a written statement setting forth the reasons and grounds why the writer of the statement believes that certain actions should be taken or decisions or recommendations made. “Order Nisi” means an order of the Commission that certain actions shall be taken or that certain matters are approved as of a future date, thereby permitting parties affected by the Order Nisi to make any objections they may have known to the Commission. Partial Rate Application. “Partial rate application” means a request by a hospital for the amendment or establishment of a single approved rate. “Partial rate application” includes, but is not limited to, those requests enumerated in Regulation .03B(4) of this chapter. “Publish” means the insertion of a public notice concerning proposed actions, including but not limited to public hearings, in a newspaper or newspapers in general circulation in the community in which the hospital affected is located, and, if the public notice relates to a public hearing, in the Maryland Register at least 15 days before the date of the public hearing. “Rate application” and “application” mean a hospital application for rate approval, to be submitted as specified in these regulations. “Recommendation” means a written statement from the Commission's staff to the Commission, advocating a resolution of issues or approval, disapproval, or modification of certain hospital rates and procedures for evaluating the rates. “Regression analysis” means a statistical technique used to measure and control for the effect of selected independent variables (for example, percentage of Medicaid revenue) on one dependent variable (for example, bad debts). “Uncompensated care” means care provided for which compensation is not received (that is, any combination of bad debts and charity care), and as more fully described in the Commission's Accounting and Budget Manual for Fiscal and Operating Management which is incorporated by reference at COMAR 10.37.01.02. “Value of the substantial, available, and affordable coverage (SAAC) differential” means the difference between the amount paid out by SAAC-approved nonprofit health service plans, health insurers, and health maintenance organizations on behalf of SAAC enrollees to hospitals, and what they would have paid to hospitals absent the differential. The Alternative Rate Setting Method (ARM) Manual (1998) is hereby incorporated by reference. The rate review system, otherwise known as the Accounting and Budget Manual for Fiscal and Operating Management, shall consist of: The rate review forms; and Instructions for completion of the forms. The rate review system is incorporated by reference in COMAR 10.37.01.02. A hospital's rate review system and a schedule of published rates shall be filed by the last day of the third month after the close of the hospital's fiscal year. A hospital may not file a full rate application with the Commission until the Commission staff is able to determine through analysis that the data used to evaluate a full rate application has not been substantially affected by the COVID pandemic. During this interim period, a hospital may seek a rate adjustment under any other administrative remedy available to it under existing Commission law, regulation, or policy. In no event shall this moratorium continue in effect beyond June 30, 2023. Once the moratorium is lifted, a hospital may file a regular rate application at any time if: The rates being requested are not the subject of a hospital-instituted case pending before the Commission; or The subject hospital has not obtained permanent rates through the issuance of a Commission rate order within the previous 365 days. Full Rate Application. “Full rate application” means a regular rate application which requests the amendment of more than one previously approved rate. In order for a full rate application to be docketed, it shall comply with a template for such applications as prescribed by the Commission staff and shall: Enumerate the services for which new rates are being requested, listing present and proposed rates; Be accompanied by appropriate supporting documents, including: The Annual Report of Revenues, Expenses, and Volumes projected and explained (e.g., how much of the requested increase relates to inflation, volumes, and other factors) for the period for which the hospital requests new rates; Any audited financial statements over the most recent 5 years not yet filed with the Commission, plus the most recent unaudited financial statements for the current period, which are available at the time of the filing of the full rate application; An Excel file listing and summarizing balance sheets, statements of operations and changes in net assets, and statements of cash flow for the last 5 years per the audited financial statements along with a narrative explaining any major changes; An Excel file listing the information contained within the Annual Report RE schedules for the last 5 years breaking out regulated and unregulated revenues and expenses by category and in total; A detailed history of HSCRC-approved revenue and actual revenue for the hospital for the last 2 calendar years; A detailed history for the most recent 4 Rate Years of HSCRC-approved GBR revenue and actual revenue and volumes, in addition to any approved and actual revenue and volumes available at the date of the filing of the full rate application. The history of approved and actual revenue changes should detail the basis of the changes in approved and actual revenue including allowed inflation and all other factors; An identification of related organizations (i.e., an organization related to the hospital through some type of control or ownership), including subsidiaries of the hospital as well as hospitals that are part of the same hospital system as the applicant hospital. For applicant hospitals that are part of a system, the hospital may be required to submit financial and other information related to the system hospitals, including any system transactions among the system hospitals, which may affect the financial condition of the applicant hospital; A listing of any services provided by related organizations including the amount charged to the applicant hospital for the services; A listing of any transfers of funds to or from a related organization including an explanation of such transfers; Copies of the two most recent Medicare Cost Reports, including any home office cost report files — the Interns and Resident Information System report (IRIS) files, and the wage and occupational mix files, along with any adjustments and corrections; Reconciliations of inpatient and outpatient volumes and revenue submitted in the HSCRC abstract data to the departmental revenue and statistics submitted monthly for the last 3 years; In Excel, listing of Outpatient drugs accounting for at least 80 percent of the Hospital’s total outpatient drug expenses, with applicable HCPCS codes for last 3 years, including frequency of charges, amount of charges and units billed, Average Sales Price at the end of each year and applicable 340B discounts and an estimate of billed charges for unlisted drugs; For profits or losses associated with the support of physician practices, the applicant hospital may be required to provide a detailed accounting of those profits or losses over time. Additional information regarding compensation, subsidies and other forms of financial support provided to physicians may be required following staff’s initial review to the extent that these profits or losses have a material impact on the financial condition of the applicant hospital; A supporting document, in Excel, that compares the requested departmental rates of the applicant hospital to that hospital’s current departmental rates. The supporting document should also compare these current and requested departmental rates to those of other HSCRC-regulated hospitals located in the Primary Service Area (PSA) of the applicant hospital. If no other regulated hospitals are located in the applicant hospital’s PSA, then the comparison should be made to Statewide median departmental rates; and An accounting of the amounts reported by the applicant hospital to the HSCRC regarding its uses of population health infrastructure money included in rates; Include a description of the rate adjustments that are being requested in the full rate application; Include specific detail and substantiation of any circumstances the applicant hospital cites as unique to its facility, which would require revenue in excess of the amount currently provided in its approved regulated revenue; Describe in detail what the applicant hospital has specifically done consistent with the All-Payer Model to reduce or eliminate unnecessary or potentially avoidable utilization. For purposes of this regulation, unnecessary or potentially avoidable utilization means the utilization of health care items and services, including care furnished to treat complications during a hospital admission, that may be avoided through improved efficiency, care coordination, or effective community-based care, or that is not medically necessary or evidence-based care. The Staff may request additional information as needed; Provide estimates for the next 5 years of reductions in utilization that will be accomplished through care redesign initiatives; Provide a history of denials for the most recent 3 years, including any year-to-date figures; and Any additional information the Staff may request that bears directly on the hospital’s request for rate relief and its financial condition. The provisions of §B(2) of this regulation may be waived by staff if the application applies only to: A request filed for a change in the applicant hospital’s uncompensated care allowance; A request for rates to cover government-mandated or similar action affecting more than one previously approved rate for which the staff believes the provisions of §B(2) of this regulation are not necessary; or A request for rates associated with a Certificate of Need-approved capital project, which request may be considered to be a “partial rate application” by staff. Uncompensated Care Policy. The Commission's rate-setting methodology shall include in the rates of each hospital a provision for a reasonable level of uncompensated care provided at the hospital. The Commission may use a regression analysis or other statistical method to establish the reasonable level of uncompensated care. In establishing a reasonable level of uncompensated care in a full rate review, the Commission shall consider for each hospital the: Amount of uncompensated care actually incurred; Predicted amount of uncompensated care; and The hospital's requested amount. A hospital may request a change in its approved provision of uncompensated care to the predicted amount by means of a partial rate application provided the request is revenue neutral. The provisions of Regulation .03B(2) of this chapter may be waived by staff in the review of a partial rate application. A hospital may file a partial rate application with the Commission at any time, consistent with the provisions of Regulation .03A of this chapter. A partial rate application is not a contested case under the provisions of the Administrative Procedure Act. The Commission shall act on a docketed partial rate application within the time frames established for a full rate application that does not involve a public hearing, consistent with Commission law and regulation. A hospital that has been denied its request for a partial rate change may file a full rate application with the Commission in accordance with Commission law and regulation. The Commission may order a review of a hospital's established rates at any time, as it deems necessary and proper. This order, provided it orders the review of any rate or charge, may constitute a Commission-initiated rate proceeding. In reviewing a hospital’s established rates during a Commission-initiated rate proceeding or while reviewing a hospital’s full rate application, the Commission shall consider the hospital’s performance since the implementation of the All-Payer Model Agreement with the federal government, which took place in February 2014. In evaluating the reasonableness of a hospital's permanent rate structure, the Commission shall use an Inter-hospital Cost Comparison (ICC) methodology, which compares the costs of the hospital to those costs, including adjustments for reasonableness and efficiency, of its peer hospitals, with appropriate adjustments to reflect changes in the hospital’s volume since the beginning of the new All-Payer Model Agreement and the inception of the hospital’s revenue agreement, as the foundation of its review of the full rate application. The staff shall make modifications to the ICC which are needed to properly reflect any additional factors that are relevant to the determination of a reasonable cost level that should be reflected in the hospital’s approved regulated revenue. The ICC analysis does not constitute a strict, unalterable or absolute methodology. It shall be modified as needed to give proper attention to the particular circumstances of the hospital, and the staff shall give due consideration to information provided by the hospital in determining the appropriate rate levels and rate structure for the hospital. The ICC shall take into account, in the establishment of appropriate rate levels, those factors for which the hospital will not be held accountable such as special grants from the Commission, assessments, uncompensated care levels, and characteristics of the population in the hospital’s primary service area. Factors considered in the ICC methodology may evolve during the course of full rate reviews. The Commission shall take into account the specific circumstances of the applicant hospital, and staff shall make the key contents, analytic steps, and findings of such reviews available to all hospitals and the public. When reviewing a full rate application filed by a hospital that is owned or controlled by a hospital system that also owns other hospitals located in Maryland, the Commission may take into account the financial situation of the other hospitals in the system including their profitability and any shifts of services, volume, revenues or assets between the hospital and the other hospitals or related organizations of the system. The final rates that are approved by the Commission for a nonprofit hospital’s permanent rate structure shall allow the hospital to charge reasonable rates that will permit it to provide, on a solvent basis, effective and efficient service that is in the public interest. The final rates that are approved by the Commission for a proprietary profit-making hospital’s permanent rate structure shall allow the hospital to charge reasonable rates that will permit it to provide effective and efficient service that is in the public interest and include enough allowance for and provide a fair return to the owner of the hospital. The Commission shall set rates for the applicant hospital consistent with the All-Payer Model approved by the federal Center for Medicare and Medicaid Innovation. 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. For purposes of this regulation, the following definitions apply: “Annual update factor” means the amount by which total State hospital revenue may increase in a rate year. “Demographic adjustment” means the percentage increase in allowed revenue related to changes in population and the age/sex mix of the population residing in the hospital’s primary service area, net of any reductions. “Factor cost inflation” means increases in the costs of goods, services, wages, and salaries experienced by the hospitals as calculated by the Commission for the most recent period for which data are available preceding the year for which the Commission calculates case target updates. “Hospital update” means the amount by which an individual hospital’s approved GBR revenue changes in a particular rate year (i.e., July 1—June 30). “Market shift adjustment” means the rate adjustment applied by the Commission, which increases or decreases the approved GBR revenue of a hospital to reflect changes in volume at the hospital for which there was a corresponding change in volume at another Maryland hospital or other provider. Annual Update Factor. On or before July 1 of each year, the Commission shall establish an annual update factor for the purpose of adjusting the GBR revenue of each individual hospital. The annual update factor shall be designed to reflect projected factor cost inflation, an allowance for certain volume adjustments, productivity adjustments, the revenue constraints included in the All-Payer Model Agreement and other relevant factors, demographic adjustments, market shift adjustments, and other appropriate adjustments. If after approving an update factor for a given year, a hospital or hospitals collectively exceed their approved revenue, the annual update factor may be reduced in future years to recoup the excess revenue growth. Similarly, if a Maryland hospital or hospitals collectively fall below their approved revenue for a given year, the annual update factor may be adjusted accordingly in future years. If Maryland hospitals accrue a national growth reduction for 2 consecutive years, in the following year the annual update factor shall be reduced by the first of the 2-year national growth reduction. Except as provided in §D of this regulation, the annual update may not be less than 1 percent. The technical provisions of the methodology used to convert the annual update factor into the hospital update for the next rate year shall be fully described and publicly disseminated on or before July 1 of each year, allowing sufficient time for comment and implementation. Corrective Action. If, at any time, the Commission estimates that the financial constraints or other terms imposed by the All-Payer Model Agreement are at risk of being violated (based on modelling using the CMS actuary’s most recent projections and Health Services Cost Review Commission analysis of Medicare payments data), the Commission may take immediate and appropriate corrective action as it deems necessary and proper to meet the Medicare savings requirements and limits on growth in Medicare payments and prevent any further deterioration in compliance with the Model Agreement. The Commission shall provide sufficient notice and opportunity for comment before taking corrective action. This comment opportunity does not constitute a contested case within the meaning of the Administrative Procedure Act. The provisions of this regulation apply to all Maryland's general acute care hospitals from July 1, 2014, and thereafter. Compliance and Penalties. GBR compliance shall be monitored during the agreement period. Penalties shall be assessed prospectively at the beginning of the next period. Penalties shall be based on the corridors specified in the GBR Agreement. The Commission may issue a general notice setting forth circumstances under which a hospital may obtain a temporary change in rates. The rates, if approved or modified, shall be effective before the rate review procedure set forth in these regulations, but not before the date of application. A hospital may apply at any time for a temporary change in rates provided that one of the following conditions is satisfied: A decline in the hospital's experienced or projected net revenues, due to factors beyond the hospital's control, requiring funds beyond those normally available; An increase in the hospital's experienced or projected expenses, due to factors beyond the hospital's control, requiring funds beyond those normally available; or A hospital's expenses from regulated services exceed its revenues from regulated services, or the hospital's financial integrity is otherwise jeopardized (for example, for breaching its bond covenants). The Commission and its staff shall review the application and consult with the hospital as to the necessity for the temporary change in rates and the amount of the change required. Designated interested parties shall have 6 working days from the filing of the application to submit comments to the Commission. Within 12 working days from the filing of the application, the Commission shall issue its order: Denying the temporary change in rates and stating the grounds therefor; or Granting a temporary change in rates, stating: The amount of the temporarily changed rates, which may or may not be the same as the rates set forth in the hospital's application; The necessity for the temporary change in rates; That a regular rate review proceeding on the proposed rates will be conducted by the Commission as soon as practicable; The availability of copies of the order at the offices of the Commissioner; and The availability of the record of the temporary rate application for inspection at the Commission's office during ordinary business hours. The Commission order denying or granting the temporary change in rates shall be published and copies forwarded to: The hospital; Designated interested parties; and Persons writing to the Commission requesting a copy of the order. In conducting an expedited review to establish a temporary rate for both inpatient and outpatient services, the Commission shall consider the hospital’s financial condition in addition to its relative efficiency and effectiveness in its performance under the Total Cost of Care Model. A temporary rate approved by the Commission may not result in regulated revenue exceeding regulated expenses in the most recently completed fiscal year. A temporary change in rates is subject to the Commission's final rate order in the regular rate review proceeding, which may be effective as of the date of the temporary rate order. At any time on or after July 1, 1974, a hospital may file a written application with the Commission requesting an alternative method for submitting or reviewing any or all of its rates and charges, specifying the reasons for and details of the alternative methods. If warranted by the circumstances set forth in the application, the Executive Director may grant a temporary approval of an alternative method of rate determination. The procedure for submitting and reviewing an application under an alternative method of rate determination shall follow as closely as possible the procedure for a regular rate application, except that the time periods and limitations set forth in these regulations do not apply to an application for an alternative method of rate determination. At anytime after the approval of an alternative method of rate review by the Executive Director, the Commission may initiate further proceedings to determine the hospital's continuing qualification for the alternative method of rate determination. ARM System. The Commission may implement a system providing for alternative rate setting methods (ARM) which would permit hospitals to accept financial risk for the provision of hospital services under certain conditions and circumstances. The implementation of an ARM system shall be consistent with the principles of equity and access embodied in the Commission's all-payer rate setting system. The ARM Manual shall set forth the process and requirements associated with the ARM system. Required Reports under ARM System. A hospital granted approval for an alternative method of charging under this regulation is required to file quarterly reports and annual reports, to include but not be limited to those listed below in this section, in order to determine that the hospital continues to qualify for the alternative method of rate determination. Quarterly Reports. The following reports shall be completed in the form prescribed by the Commission and submitted to the Commission within 30 days after the end of each hospital's calendar quarter: Statistical Data Summary—Each Capitation or Risk-Sharing Contract; Statistical Data Summary—Each Fixed-Price Contract; Statistical Data Summary—Other; Revenue Summary—Each Capitation or Risk-Sharing Contract; Revenue Summary—Each Fixed-Price Contract; and Revenue Summary—Other. Annual Reports. The following annual reports shall be completed in the form prescribed by the Commission and submitted to the Commission within 90 days after the end of the appropriate fiscal year: Statement of Revenue and Expense—Each Capitation or Risk-Sharing Contract; Statement of Revenue and Expense—Each Fixed-Price Contract; Statement of Revenue and Expense—Other; Audited Statement of Revenue and Expense—Contracting Entity; and Audited Balance Sheet—Contracting Entity. Filing of Reports/Extension. A hospital required to file the reports in this section may request a reasonable extension of time for filing, if the extension request is: Made in writing to the attention of the Executive Director; Supported by sufficient justification; and Made at a reasonable time before the due date of a required report. The Executive Director shall respond promptly in writing to the requesting hospital upon receipt of the request by either approving or disapproving the request. Extensions will be granted only for valid reasons. Any required report submitted by a hospital that is substantially incomplete or inaccurate shall be considered untimely filed. Time for Filing. An application for an alternative rate application shall be filed at least 30 days before the proposed effective date of the alternative rate. Penalties. The Commission may impose penalties of up to $1,000 per day for failing to file reports as required under this section. The Commission may refuse to grant a rate increase to a hospital that does not file a report as required under this section. A fine assessed for failure to file an alternative rate application on a timely basis shall begin as of the date the application should have been filed. Funding for Health Information Technology. The Commission may adjust a hospital's rates for health information technology (HIT) projects in conjunction with action taken by the Maryland Health Care Commission (MHCC) under COMAR 10.25.13. Upon receipt of a recommendation for funding from the MHCC, the Commission's staff shall: Review the information presented; Consult with appropriate parties; and Recommend to the Commission approval, denial, or modification of the MHCC recommendation. In deciding the course of action to follow on an MHCC HIT project recommendation, the Commission and its staff shall consider, among other things, the following criteria: The basis for the MHCC recommendation; The applicant's statement of the purpose, mission, vision, goals, and measurable objectives of the project; The planned approach, including: An explanation of how the project's goals and objectives will be met; The technical strategy of the project; What activities will be used; What personnel will be needed; and How that personnel will be utilized; How the project will be evaluated, as well as specific measurement strategies; A timeline that includes the start and end dates of the project and a schedule of activities; The credentials of the entity and participating individuals, including information that demonstrates their background and ability to carry out the project successfully; The potential of the project to enhance the value of health care in Maryland, such as improving health care outcomes and reducing health care costs; Information that demonstrates why the project is needed; and A budget that details cost projections for the project that is specific, reasonable, realistic, accurate, and flexible. Decision. Based on its consideration of the above-stated criteria and staff's recommendation, the Commission shall decide on the nature, extent, terms, and conditions of any rate adjustment approved. The decision of the Commission on an MHCC recommendation for HIT funding is final. A request for funding under this section is not a contested case under the Administrative Procedure Act. At least 60 days before the operational opening of a new hospital, a revenue center, or a new service within a hospital whose projected annual operating cost exceeds $100,000, the hospital shall file a rate application for the requested rates. This application shall be supported by financial data presented in the format of the Commission's rate review system. If an existing hospital expends its operations so that the number of in-patient beds is increased by 20 percent or more, and if a rate application is filed pertaining to the expended facilities and providing for an occupancy rate for the expanded facilities of the hospital at an amount below the target occupancy established by the Commission, the Commission may require the filing of additional information projecting the hospital's expanded facilities' activity levels for the first 5 years of their operation. Definitions. In this regulation, the following terms have the meanings indicated. Terms Defined. “At the hospital” means a service provided in a building on the campus of a hospital in which hospital services are provided. “Health care provider” means an individual who is licensed, certified, or otherwise authorized by law to provide health care services under Health Occupations Article, Annotated Code of Maryland. “Telehealth services” means the delivery of health care services provided through the use of interactive audio, video, or other telecommunications or electronic technology by a health care provider at a hospital to a patient at a location other than at the hospital, or to a patient at the hospital where the provider is at a location other than the hospital, which enables the patient to interact with the health care provider at the time the health care services are provided. A service at the hospital is: Presumed to be an outpatient service; and Subject to rate regulation. In accordance with Health-General Article, §19-201, Annotated Code of Maryland, the Commission’s rate-setting jurisdiction extends to outpatient services provided at the hospital. Outpatient services associated with the federal 340B Program under the federal Public Health Service Act provided in a department of a regulated hospital that, on or before June 1, 2015, is under a merged asset hospital system, and which are physically located at another regulated hospital under the same merged asset hospital system, shall be subject to the rate-setting jurisdiction of the Commission. The Commission may begin setting rates for these services in anticipation of the hospital’s obtaining provider-based status for purposes of the 340B Program. A hospital that desires an exception to the presumption stated under §C of this regulation must receive a determination under the provisions of this regulation. Commission Approval. A hospital may not charge a Commission-approved rate for an outpatient service without prior Commission or Commission staff approval. A hospital may not open a new outpatient service, relocate an existing outpatient service, or convert an existing outpatient service from regulated or unregulated status without a prior determination from the Commission’s staff as to whether the service is being provided at the hospital. A request for determination shall be made in writing at least 60 days before the contemplated action. Upon request for an exception under §D of this regulation, the Commission's staff shall: Review the information presented; Consult with appropriate parties; Visit the site of the service as it considers necessary; and Notify the hospital of its determination as soon as practicable. In deciding whether an outpatient service is at the hospital, the Commission staff may consider, among other things, the following criteria: Location of the entrances; Location and signage of parking; Location and language of signage at entrances, within buildings, on the campus, and in parking areas effectively alerting the public that a given building or service is either at the hospital or not at the hospital; Location of registration, changing, and waiting areas; Whether billing reflects clearly that the service is rate regulated or not rate regulated; Whether any physical connection from an unregulated facility to the hospital, such as tunnels, hallways, covered walkways, elevators, or connecting bridges, will be restricted to hospital staff and physician use in order to ensure that patients and visitors do not have access to the unregulated facility from the hospital; Whether there is any duplication of an unregulated service within the hospital in order to avoid inappropriate patient steering; Whether there is any inappropriate mixing of regulated and unregulated services in the same building, which would tend to have the effect of confusing patients about the regulated or nonregulated status of a given service being provided; and Whether any Medicare Part B physician's service being provided in an unregulated building also includes components of a Medicare Part A hospital service that would be reasonably expected by a patient to fall under Commission rate-setting jurisdiction. Based on consideration of the criteria stated in §G of this regulation, the Commission's staff shall make its determination on the request made under §E of this regulation. A hospital that fails to obtain or violates a staff determination on the hospital status of a given service may be subject to fines for inaccurate reporting under COMAR 10.37.01.03R and paybacks for inappropriate charges made during the time a staff determination on an outpatient service was not obtained or adhered to. A request for a determination under this regulation is not a contested case under the Administrative Procedure Act. A hospital may not bill a separate hospital facility fee when a health care provider who provided telehealth services is authorized to bill independently for the professional services rendered. The delivery of telehealth services as described in §A(2) of this regulation constitutes outpatient services provided at the hospital. Definition. In this regulation, “freestanding medical facility” means a freestanding medical facility licensed under Health-General Article, Title 19, Subtitle 3A, Annotated Code of Maryland. The following outpatient services provided at a freestanding medical facility are considered hospital services under Health-General Article, §19-201, Annotated Code of Maryland: Emergency Services; Observation Services; and Associated Ancillary Services, such as laboratory, radiology, imaging, EKG, and Medical/Surgical Supplies and Drugs. In accordance with Health-General Article, §19-201, Annotated Code of Maryland, the Commission’s rate-setting jurisdiction extends to those outpatient services provided at a freestanding medical facility, as designated by the Commission. A freestanding medical facility or a proposed freestanding medical facility that desires to provide a service not designated in §B of this regulation (an undesignated service) must receive a determination under the provisions of this regulation. Commission Approval. A freestanding medical facility may not charge a Commission-approved rate for an undesignated service without prior Commission staff approval. A freestanding medical facility may not open a new outpatient service, relocate an existing outpatient service, or convert an existing outpatient service from regulated or unregulated status without a prior determination from the Commission’s staff as to whether the service constitutes a hospital service subject to Commission rate regulation. A request for determination shall be made in writing at least 60 days before the contemplated action. Upon request for a determination, the Commission’s staff shall: Review the information presented; Consult with appropriate parties; Visit the site of the service as it considers necessary; and Notify the freestanding medical facility of its determination as soon as practicable. In deciding whether the service constitutes a hospital service subject to Commission rate regulation, Commission staff shall consider, among other things, the following criteria: Cost of the service; In consultation with Maryland Health Care Commission (MHCC) staff, access to and need for the service in the community; Feasibility of providing the outpatient service in the community on an unregulated basis; and Impact of the service on the All-Payer Model including, but not limited to, the Total Cost of Care limitations as prescribed in the All-Payer Model Agreement with the Center for Medicare and Medicaid Innovation. Based on the consideration of the criteria stated in §G of this regulation, the Commission staff shall make its determination on the request made under §E of this regulation within a reasonable period of time, taking into account, among other things, whether either a Certificate of Need application to establish a freestanding medical facility or a request for exemption from Certificate of Need to convert a licensed general hospital to a freestanding medical facility is pending before the MHCC and, if so, the time frame for staff to comment to MHCC on the financial feasibility of the proposed project. A freestanding medical facility that fails to obtain, or violates, a staff determination on the regulated status of a given service may be subject to fines for inaccurate reporting under COMAR 10.37.01.03R and paybacks for inappropriate charges made during the time a staff determination on an outpatient service was not obtained or adhered to. Each rate application shall include a list of services for which new rates are being requested, a list of the present and requested rates, and shall be based on the currently filed or required rate review system. The application may be filed by private messenger at the Offices of the Commission, or may be filed by registered mail, return receipt requested, at the following address: Health Services Cost Review Commission 4160 Patterson Avenue Baltimore, Maryland 21215 Docketing. When a valid rate application is received, as per the above regulations, it shall be entered on the Commission docket and a file opened. Each rate application shall be given an annual docket number and a consecutive page number in the docket. Each rate application shall be given a consecutive file number. A regular rate application file number shall be noted “R”. The file number of an order authorizing Commission investigation and review of established rates shall be noted “C”. A temporary rate application file number shall be noted “I”. An alternative method of rate determination application file number shall be noted “A”. A rate application file number by a new hospital or a hospital with expanded facilities or new revenue centers shall be noted “N”. The date of receipt of the rate application shall be noted on the docket and on the file. Upon request of the hospital, the Commission shall give the hospital a receipt for the rate application filing, showing the docket, page, and file numbers, and the date of receiving the rate application. The hospital shall file an original and three copies of each rate application and its supporting documents, if any. The Commission may prescribe the format to be used in the submission of rate applications and their supporting documents. In addition, the hospital shall file with each rate application a certificate of service indicating that the application and supporting documents have been mailed or served upon all designated parties to that proceeding and upon the Commission at its offices. A rate application review shall be completed and the recommendation given to the Commission as soon as possible. The recommendation shall include a specification of those areas of costs which the staff believes should be reviewed. When practicable, the recommendation shall also include the amounts challenged by the staff. Any of four actions may be recommended to the Commission. If two or more actions are recommended, the issues and rates to be evaluated in each action shall be set forth clearly. These four actions are as follows: The Commission should hold a public hearing on rates; The Commission should grant tentative approval or modify all or some of the rates and publish notice of an order nisi; The Commission should hold a general hearing on rates; The Commission should deny the application in which case it shall state the grounds for the denial. A copy of the recommendation shall be placed in the file and a copy shall be forwarded to each Commission member, the hospital, and each interested party. The Commission may not call for the effective date of an Order Nisi or call for a public hearing for 30 days after the Commission acts on the staff's recommendation. Before a staff recommendation or public hearing, the staff may hold conferences with hospital representatives and interested parties in an attempt to clarify or resolve potential issues. The Commission may prescribe a process for its consideration of a full rate application, which allows for written submissions in support of an application in lieu of an evidentiary hearing. A hospital that chooses this process for a Commission decision on its full rate application shall be afforded the right to submit to the Commission rebuttal information following any written response to the full rate application filed by Commission staff or designated interested parties. A hospital that chooses this written submission process waives its right to an evidentiary hearing. A hospital that chooses this written submission process does not waive its right to judicial review of a final Commission decision under the Administrative Procedure Act. As an additional alternative to an evidentiary hearing, a hospital may choose to enter into a binding arbitration process as prescribed by the Commission. The Commission shall consider the staff recommendation and, within 20 days of the date of the recommendation, issue its preliminary order adopting or modifying the recommendation, or referring the recommendations back to the staff for further review and subsequent recommendations. Order Nisi. If the Commission issues a preliminary order granting tentative approval of any rates, it shall publish notice of the order nisi and the rates. In addition, the Commission shall forward copies of the order nisi and the rates to the hospital and interested parties. The order nisi shall state: The name and address of the hospital; the names of the designated interested parties; the docket, page, and file numbers of the rate application proceeding and the date the application was filed with the Commission. An enumeration of services and the proposed representative rates to be charged: That the Commission has approved the rates as of a date to be specified, with a provision that the order may be suspended if reasonable cause is shown within 15 days of the date of the Order Nisi. That objections to the tentatively approved rates shall be submitted (in person or by mail) to the Commission in writing; that designated interested parties shall submit copies of their objections, identifying the proceeding and Order Nisi to which objections are made to the hospital, and nine copies to the Commission office; and That the file, which may contain supporting documents from the hospital, the Commission staff recommendation, the Accounting and Reporting reports and the Rate Review System of the hospital, is available at the Commission offices during regular business hours for public inspection. If the Commission issues an order for a public hearing, it shall forward copies of the order and public notice of the hearing to the hospital and the designated interested parties and shall publish a public notice of the hearing. The notice shall state: The name and address of the hospital: the names of the designated interested parties; the docket, page, and file numbers of the rate application proceeding; the date the application was filed with the Commission; and the time, date, and place of the hearing; A description of the issues to be presented at the public hearing; That any person interested in the matter may attend the public hearing; That all persons wishing to present relevant testimony or a statement at the public hearing shall forward copies to the hospital, each designated interested party, and nine copies to the Commission office; that the hospital and members of the public shall forward their testimony at least 8 days before the hearing; that the designated interested parties shall forward their testimony at any time before the close of the first session. Written testimony will not be considered unless the person submitting the testimony makes himself available for cross-examination unless stipulated to the contrary. If the Commission issues an order for a general hearing by the Commission, it shall forward copies of the order and public notice of the hearing to the hospital and the designated interested parties and publish a public notice of the hearing. Testimony shall be in writing and may not be delivered orally, except as set forth in Regulation .14K, of this chapter. Presenting Direct Testimony. Any person who wishes to present direct testimony at the public hearing shall forward copies to the hospital and to every designated interested party, and shall file nine copies at the Commission's office. If the public hearing is the result of a hospital rate application pursuant to Regulation .03, of this chapter, the applicant shall file its testimony at least 20 days before the date of the hearing. The staff of the Commission and members of the public shall file their testimony at least 10 days before the date of the hearing. If the public hearing is the result of a Commission-initiated review of the rates of a hospital pursuant to Regulation .04, of this chapter, the Commission staff shall file its testimony at least 20 days before the date of the hearing. The hospital and members of the public shall file their testimony at least 10 days before the date of the hearing. The designated interested parties shall file their testimony before the close of the first hearing session. The written direct testimony shall set forth the conclusions of the person submitting it and the arguments and facts supporting these conclusions. This testimony shall specifically pertain to the issues set forth in the public notice. Written direct testimony shall be verified either by: Appearing before an officer or other person authorized to administer an oath; or Signing the documents containing the statements required to be under oath and including the following representation: I do solemnly declare and affirm under the penalties of perjury that the facts set forth in the foregoing testimony are true and correct to the best of my knowledge, information and belief. Copies of written direct testimony shall be forwarded by the person submitting them to the hospital and the designated interested parties. All written direct testimony shall pertain solely to the proposed rates and be relevant to that subject. The presiding officer shall separate irrelevant material from the remainder of the record and keep that material apart. Parts of the body of the written direct testimony judged irrelevant by the presiding officer shall be so marked and may not be considered by the Commission in its deliberations. Persons submitting written testimony shall make themselves available for cross-examination and may give redirect and rebuttal testimony, orally or in writing, as directed or permitted by the presiding officer. All testimony at public hearings shall be filed in a timely manner. Requests for hearing postponements shall be made at a reasonable time before the hearing. These requests will only be granted for valid reasons, at the discretion of the Commission. If a hospital requests a postponement of an initial hearing session after the staff has already submitted its testimony, the Commission may require the hospital to file its testimony within the time frame of the original hearing date. The Chairman of the Commission shall preside at the public hearing, which may be called to order when the presiding officer is in attendance. If the Chairman is absent or has been disqualified, the Vice-chairman or another commissioner shall preside. The Commission may direct that a hearing officer preside at the public hearing. In this case, the hearing officer may exercise all powers given to a presiding commissioner in these regulations during all sessions of the public hearing. At the discretion of the Commission, the specific duties of the hearing officer may include the following: Making all rulings as to evidence, testimony, and official notice; Setting the order for the examination and cross-examination of witnesses; Administering oaths and affirmations; Preparing both written and oral summaries of cases heard; Preparing a recommendation for the Commission consisting of a written report with findings of fact and conclusions of law. The presiding officer may adjourn a hearing to a specified time, date, and place. All public hearings shall be recorded and testimony shall be under oath. A transcript of the record of the hearing shall be placed in the file of the proceeding. If the hospital or any other party desires a copy of the transcript, that party shall make arrangements with the stenographer. All direct testimony shall be submitted in writing and in an issue-by-issue format. The hearing shall begin with the examination of the representative of the hospital and any witnesses which the hospital may desire to have testify in its behalf. Whenever practicable, the testimony of witnesses shall proceed on an issue-by-issue basis. The Commission's staff member assigned to the proceeding shall be the next witness to be examined on the issue in question. In a Commission initiated review, the staff member assigned to the proceeding shall be examined before the hospital witness. Representatives of the other interested parties who have submitted written testimony shall be examined in the order set by the presiding officer. The Commission may examine witnesses at any time during the course of the proceeding. Commission staff and representatives of the hospital and interested parties may also examine witnesses. All testimony and examination shall be relevant to the subject of the proposed rates. Redundant and irrelevant testimony and examination shall be prohibited or stricken by the presiding officer. In addition, all interested parties may move the Commission to strike redundant and irrelevant testimony. At the presiding officer's discretion, he may allow direct oral testimony if a person attending the hearing demonstrates good cause for not submitting the testimony in written form before the hearing. Witnesses giving direct oral testimony shall be subject to cross-examination in the same manner as other witnesses. Anyone denied an opportunity to testify may appeal in writing to the full Commission within 7 days from this denial. To preserve his rights on appeal or otherwise, it is not necessary for a party objecting to a Commission ruling or decision to state the grounds of his objection, unless specifically requested to do so by a member of the Commission. At the Commission's reasonable discretion, it may permit the filing of post hearing briefs by the hospital, the Commission staff member or any interested party. Those parties submitting briefs shall file copies within a reasonable time designated by the presiding officer to the hospital, the designated interested parties, the Commission office and to each Commission member. A Commission member shall remove himself from participation in a public hearing as a Commission member if he decides that a conflict of interest may appear to prejudice his evaluation of the issues considered at the public hearing. Challenges to a Commission member's participation in a public hearing as a Commission member shall be considered by the Commission, the decision made by a majority vote, excluding the member objected to. Challenges shall be made by motion, at least 7 days before the public hearing. Except as otherwise provided, all decisions required during the conduct of the public hearing shall be made by the presiding officer. The decision and the opinions of the Commission shall be based solely on the testimony, examination, and evidence presented at the public hearing, on the briefs filed, if any, on the evidence incorporated into the record of the proceeding by reference, on information and data in the record of the proceeding, and on matters as to which the Commission has taken official notice, which matters shall be made known to the parties to the proceedings. The deliberations of the Commission may be held in private executive session. The decision shall be made by a majority of the Commission members attending all sessions of the public hearing, or having read the record of hearings they did not attend. The decision shall be in writing and shall be based on a written majority or unanimous opinion stating the reasons and grounds for the Commission's decision. If a majority of Commissioners who are to render the final decision have not heard the evidence, the decision, if adverse to a party to the proceeding other than the Commission itself, may not be made until a proposal for decision, including findings of fact and conclusions of law, has been served upon the parties, and an opportunity has been afforded to each party adversely affected to file exceptions and present argument to a majority of the Commissioners who are to render the decision, who shall personally consider the whole record or those portions of it as may be cited by the parties. At the discretion of a Commission member (or members) who agrees with the decision reached by the majority of the Commission, but who does not agree with the majority opinion, or any part of it, the Commission member (or members) may file a written concurring opinion. A commission member (or members) who does not agree with the decision or any part of it reached by the majority of the Commission may, at his discretion, file a written dissenting opinion. The Commission's decision and the opinion (or opinions) shall be filed promptly and the Commission's staff then shall forward copies of the Commission's decision and the opinion (or opinions) to the hospital, to the designated interested parties, and to those parties who submitted written direct testimony before the public hearing. The Commission shall then publish: An order approving, modifying, or disapproving the rates under review in the proceeding: A notice that copies of the Commission's decision and the opinion (or opinions) may be obtained by written request to the Commission offices; and A notice that the record of the complete proceeding is open for public inspection at the Commission offices during regular business hours. To obtain general information from the region and community in which a hospital is located, the Commission, at its discretion, may hold a general hearing during the course of any rate proceeding. A general hearing shall be supplementary to other methods of rate review and may not replace them. A general hearing shall be held in the region in which the hospital whose rates are being reviewed is located. The public notice of a general hearing may state: The name and address of the hospital, the designated interested parties, the docket, page, and file numbers of the application, and the time, date, and place of the hearing; A description of the issues to be considered at the general hearing; That any party interested in the matter may attend and present written or oral statements concerning the announced issues; and That presentations may be limited as to time and that the number of spokespersons representing any group or organization may be limited. The general hearing shall be conducted by a hearing officer, any member of the Commission, a senior member of the Commission staff or its legal counsel. Persons attending the general hearing may present written or oral statements concerning the issues and rates set forth in the notice, which statements need not be verified. The presiding officer, within his discretion, may limit the number of spokespersons representing a group or organization and may limit the time allowed for oral statements. The conduct of the general hearing shall be recorded and the transcript shall be placed in the file of the proceedings. Any person may purchase a transcript of the hearing from the stenographer. The presiding officer may ask questions of the spokespersons. Within the discretion of the presiding officer, examination or questions of the spokespersons by other persons may be permitted. A transcript of the oral statements and copies of the written statements shall be placed in the Commission's file of the particular rate review proceeding. The following forms are illustrative of pleadings and papers commonly used by parties in rate review proceedings and should be used wherever possible and, if necessary, adapted to the facts in the proceeding and the needs of the party using the forms: Rate Application. Public Notice of Rate Proceeding. Notice of Public Hearing. Notice of General Hearing: Notice of Orders Nisi. Order Nisi. Orders. Motions. Service. ________________________________________________________________________________________________________ (Signature of party filing pleading) Subpoena Duces Tecum for Rate Review. __________ (date) ________________________________________________________________________________________ Health Services Cost Review Commission Summons for Rate Review. __________ (date) ________________________________________________________________________________________ Health Services Cost Review Commission Summons for Hearing. __________ (date) ________________________________________________________________________________ Health Services Cost Review Commission Subpoena Duces Tecum for Hearing. __________ (date) ________________________________________________________________________________________ Health Services Cost Review Commission All pleadings, motions, and other papers filed in a Commission proceeding shall be typed or legibly written on sheets of bond paper not more than 11 inches long or 8-1/2 inches wide, and each paper shall have a left margin of at least 1 inch and a top margin of at least 1-1/2 inches. All pleadings, motions, and other papers, excluding exhibits appended to the pleadings, shall contain a heading at the top of the first page and, excluding appended exhibits and written direct testimony for a public hearing, a certificate of service at the bottom of the last page. A rate application filed by private messenger at the offices of the Commission shall be deemed to be filed on the date the application is received during normal working hours in the Commission's office. A rate application sent by registered mail shall be deemed to be filed 3 days after the application is placed in the U.S. Postal Service, these days to exclude Saturdays, Sundays, and holidays on which mail is not delivered to the Commission. The rate application's file date shall be entered on the docket of the proceeding. An original and three copies of all other pleadings, documents, testimony, or motions to be considered by the Commission shall be filed at the office of the Commission during regular business hours. All pleadings, documents, testimony, or motions shall contain a certificate of service indicating that the pleading, document, testimony, or motion has been mailed or served upon all designated parties to that proceeding and upon the Commission at its offices. In computing any period of time prescribed by these regulations, by order of the Commission or by any applicable statute, the day of the action or default initiating the designated period of time not be included. The last day of the period so computed is to be included unless it is a day on which the office of the Commission is closed, in which event the period runs until the end of the next day on which the office of the Commission is open. When the period of time allowed is more than 5 days, intermediate Saturdays, Sundays, and legal holidays shall be considered in the same manner as other days, but if the period of time allowed is 5 days or less, intermediate Saturdays, Sundays, and legal holidays may be not counted in computing the period of time. At the discretion of the Executive Director or his designee and, upon reasonable cause being shown by the submitting party, a period of time to submit a document or perform any other act permitted or prescribed by these regulations may be extended for a reasonable period of time. Motions shall be in writing, except when made at a hearing or conference and shall state concisely the question which the Commission is called upon to determine, or the action the movant desires the Commission to take. It shall state all reasons, authorities, and citations in the body of the motion or in a supporting memorandum. A certificate of service, setting forth all parties upon whom a copy of the motion was served, shall be attached to the motion. The following actions shall be taken by motion: Objections to actions of the Commission, or the Commission's staff; motions for clarification or reconsideration may not stay the orders of the Commission; Demands for actions which the movant desires the Commission, or the Commission's staff to take; Showing reasonable cause why an Order Nisi should not become effective; Presenting a proper and justifiable question to the Commission; Objections to the introduction of statements or other evidence by another party during a proceeding; Challenges to members of the Commission; Proposals for stipulations; Answers to prior motions; and All other actions which might be initiated properly or undertaken by a party to a proceeding and which are not otherwise provided for in these regulations. The motion shall be filed with the Commission and a copy shall be served on each affected party. A motion need not be verified unless it is based upon facts not apparent from the record or documents filed in the proceeding. Any affected party may answer an initial motion. The method of considering the motion, whether by executive communication, private hearing, or public hearing shall be determined by the chairman of the Commission. The Commission shall decide upon the question presented or action demanded in the motion in an equitable manner and as soon as practicable. Except when a motion is made at a conference or a hearing, the order granting or denying the motion shall be in writing and shall be entered on the record of the proceeding and copies of the order shall be served upon the moving party and all affected parties. The decision expressed in the order shall be decided pursuant to these regulations, if provision is made. If no provision is made, the motion shall be decided by a majority of the Commission. However, motions made in the course of a private conference or at a public hearing shall be decided by the presiding officer or a majority of the Commission attending the session of the conference or hearing at which the motion was made, as provided elsewhere in these regulations. Motions made in the course of a general hearing shall be decided by the hearing officer. At any time, the Commission may issue subpoenas directing a designated person to do the following: Appear to testify at a hearing or private pre-hearing conference conducted by the Commission: Appear at a specified time and date at the Commission offices or any designated place within the State, and, under oath or otherwise, give testimony and answer questions of the Commission or its authorized representatives; or Produce documents, reports, or records of a particular activity for a specific period of time if he has custody of or access to the documents, reports, or records; the records may be in any reasonable form; the production shall be made at a specified time, date, and place. A subpoena shall be in whatever form is prescribed by the Commission and shall include: The name, title, if any, and address of the person upon whom it is to be served and the address at which it is to be served; The name(s), title(s), or position(s) of the witness(es) who shall appear and the time, date and place of their appearance. A reasonable specification of the documents, reports and/or records, if any, to be produced at the designated time, date and place. Subpoenas shall be served at least 7 days before any public hearing or private or pre-hearing conference or executive session of the Commission at which the witness or witnesses are directed to appear, and shall be served at least 3 days before a private appointment. Subpoenas shall be served in person by a person designated by the executive director or, at his discretion, by registered or certified mail, return receipt requested. A signed return of the service or the return receipt shall be entered in the file and noted on the docket of the proceeding. A witness or a party with whom he is associated or affiliated may move to quash or modify the subpoena directed to him at any time before the date set for his appearance by filing with the Commission a motion to quash or modify the subpoena as provided in that section which pertains to motions in general. Failure to appear or to produce documents in accordance with a subpoena shall subject the witness or the party with which he is affiliated or associated to a finding of contempt by the Commission and other penalties provided by law or these regulations. The effective date of rates applied for in a rate application shall be 30 days from the date of the filing of the rate application with the Commission and shall be specified in the rate application. The Commission's staff may recommend the suspension of the effective date of the rates under review. At any time during a rate review, the Commission may order a suspension of the effective date of the rates under review, within the time specifications of Health-General Article, §19-219, Annotated Code of Maryland, and shall state the grounds for its action. The presiding officer at a public hearing or general hearing shall make all rulings as to evidence, testimony, and official notice and he may call on the legal counsel of the Commission for guidance in his rulings. All evidence and testimony shall be relevant and pertain solely to the issues being considered in a particular proceeding. Redundant evidence or testimony may not be permitted at public or general hearings or in the records of proceedings. Non-expert opinion testimony may be considered at a hearing and documentary opinion evidence may be entered in the record of a proceeding if the testimony or evidence is based on facts and matters admissible into evidence and the facts and matters are within the personal knowledge of the submitter of the document. Qualification as an expert shall be within the discretion of the presiding officer of the public or general hearing at which the proposed expert may proffer testimony or evidence or, if evidence is proffered at a time other than at a public hearing, within the discretion of the chairman of the Commission considering the proceeding. The expert qualification need not be based upon academic degrees or learning; reasonably extensive practical experience with the subject may be sufficient for an expert qualification. Subject to the provisions of these regulations, legal rules of evidence shall be followed as far as practicable at public and general hearings. Reliable and probative documents previously filed with or compiled by the Commission or its staff or consultants that are relevant to issues being considered by the Commission may be incorporated by reference into the record of a proceeding by the Commission or, by leave of the presiding officer, by a party to the proceeding. In the course of a proceeding, the Commission may take official notice of facts and matters in the same manner as the courts of the State take judicial notice of facts and matters and, additionally, may take notice, without meeting formal evidentiary rules, of general, technical, or scientific facts within the specialized knowledge of a member of the Commission. However, any party to the proceeding is entitled, on timely request, to an opportunity to show that the Commission should not take official notice of specific facts and matters or that the fact or matter to be officially noticed is inapplicable to the proceeding or is incorrect or misunderstood by the Commission. In reviewing a hospital's rate structure, the Commission may consider or take official notice of any public document, including, but not limited to, any filing made with the Maryland Health Resources Planning Commission relative to a Certificate of Need application including all projections of volumes, revenues, rates, and feasibility studies, as well as any public document concerning the financing of a project approved pursuant to a Certificate of Need. Definitions. In this regulation, the following terms have the meanings indicated. Terms Defined. “Debt collector” has the meaning stated in COMAR 10.37.13.01. “Hospital” means a “facility” as defined in Health-General Article, §19- 301, Annotated Code of Maryland. “Income-based payment plan” means a payment plan based on the patient’s household income as set forth in COMAR 10.37.13.05. “Payment plan” has the meaning stated in COMAR 10.37.13.01. A third-party payer may obtain a discount in rates established by the Commission if it provides current financing monies in accordance with the following terms. A third-party payer that provides current financing equal to the average amount of outstanding charges for bills from the end of each regular billing period and for discharged patients shall be entitled to a 2-percent discount. For purposes of this regulation, a regular billing period shall be based on a 30-day billing cycle. The current financing provided in here corresponds to a third party's paying on discharge. A third-party payer that provides current financing equal to the average amount of outstanding charges for discharged patients plus the average daily charges times the average length of stay, shall be entitled to a 2.25-percent discount. The current financing provided to hospitals corresponds to a third party's paying on admission. Outstanding charges shall be calculated by an amount equal to the hospital’s current average daily payment by the payer, multiplied by the hospital’s and third party payer’s processing and payment time. The precise calculation shall be made in accordance with the guidelines specified by Commission staff. Upon request from an applicant, the Commission may approve an alternative method of calculating current financing monies. The third-party payer shall adjust the current financing advance to reflect Commission rate orders and changes in volume associated with the particular payer and hospital. This adjustment shall be made within 45 days of a rate order or at such other time as circumstances warrant. In the absence of a rate order, the adjustment shall be made at least annually. The third-party payer shall promptly provide the Commission with a verified record of the detailed calculation of the current financing and of each recalculated balance as adjustments are made. The detailed calculations shall become a part of the public record. The Commission may, at any time, evaluate the amount of current financing monies provided to a hospital to assure that it meets the discount of requirements specified in §B of this regulation. If the Commission finds that the amount of current financing is inconsistent with the requirements of §B of this regulation, the Commission may, at its sole discretion, require an adjustment to the working capital advance or to the discount. Discounts. A payer or self-paying patient, who does not provide current financing under §B of this regulation, shall receive a 2-percent discount if payment is made at the earlier of the end of each regular billing period or upon discharge from the hospital. Payment within 30 days of the earlier of the end of each regular billing period or discharge entitles a payer or self-pay patient to a 1-percent discount. For those payers not subject to Insurance Article, §15-1005, Annotated Code of Maryland, after 60 days from the date of the earlier of the end of each regular billing period or discharge, interest or late payment charges may accrue on any unpaid charges at a simple rate of 1 percent per month. The interest or late payment charges may be added to the charge on the 61st day after the date of the earlier of the end of each regular billing period or discharge and every 30 days after that. For patients that have entered into a hospital income-based payment plan under COMAR 10.37.13.05, the interest rate shall be established in accordance with the Guidelines set forth in COMAR 10.37.13.05. Hospital Billing Responsibilities. A patient shall be given a bill for services at the earlier of the end of each regular billing period or upon discharge or dismissal, when dismissal for outpatients is analogous to discharge for inpatients. This bill shall cover substantially all care rendered and should, except for some last day ancillary services and excepting arithmetic errors, represent the full charge for the patient's care. A notice shall be posted prominently at the billing office of the hospital clearly notifying all patients of the availability of the discounts referred to in §D of this regulation. The bill and the notice shall state that the patient shall receive a 2-percent discount by paying upon discharge or a 1-percent discount by paying within 30 days of discharge. GME Discounts. In those instances where a teaching hospital is reimbursed separately for the costs associated with the provision of graduate medical education (GME), the Commission shall calculate the percentage of the hospital's rates that these GME payments represent and provide notice of the amounts that may be credited toward the payment for services rendered. At all times, total payment received by the teaching hospital shall be in accordance with Commission-approved rates. The Commission shall determine and assess those funds necessary to operate and administer the MHIP. The Commission shall adjust hospital rates to implement the revenue neutral assessment. The Commission shall assess each hospital up to 1 percent of its net patient revenue to operate and administer the MHIP. There shall be no MHIP assessment for Fiscal Year 2016. Beginning on September 5, 2003, each hospital whose rates have been approved by the Commission shall remit monthly, by the 5th of each month, 1/12 of its total share of the annual funding assessment determined by the Commission to be owed by the hospital to the Maryland Health Insurance Plan Fund as established under Insurance Article, Title 14, Subtitle 5, Annotated Code of Maryland. A hospital that fails to remit its funding assessment due in a timely manner may be subject to an annualized interest charge of 3 percentage points above the most recent average prime rate of interest, as published in the “Money Rates” section of The Wall Street Journal, on the unpaid balance. In addition, the Commission may impose penalties of up to 5 percent of the amount of any underpayment made by the hospital. Beginning July 1, 2008, the Commission shall assess annually a uniform, broad-based, and reasonable amount in hospital rates to reflect the aggregate reduction in hospital uncompensated care resulting from the expansion of health care coverage under Ch. 7, Acts of 2007 Special Session. Given the prospective nature of the rate system, the Commission shall ensure that the assessment amount does not exceed the savings projected in averted hospital uncompensated care from the health care coverage expansion. The Commission shall notify hospitals annually of the amount to be assessed by July 1 of each year, to be effective July 1. Beginning September 2008, on or before the 5th business day of each month, each hospital assessed in accordance with Health-General Article §19-214, Annotated Code of Maryland, and the provisions of this regulation shall make payment into the Health Care Coverage Fund established under Health-General Article, §15-701, Annotated Code of Maryland. A hospital that fails to remit its monthly funding assessment in a timely manner may be subject to an annualized interest charge of 3 percent the most recent average prime rate of interest, as published in the “Money Rates” section of the Wall Street Journal, on the unpaid balance. In addition, the Commission may impose penalties of up to 5 percent of the amount of any underpayment made by the hospital. Designated interested parties for a specific rate review proceeding may include: Those community oriented groups which the Commission determines have a significant interest in the hospital and its rate application; Those third-party payors or their representatives who have been designated by the Commission as interested parties for this proceeding; The hospital whose rates are being reviewed; Maryland Health and Higher Educational Facilities Authority for rate review proceedings concerning hospitals with capital financing through the Authority. Group Hospitalization, Incorporated, for rate review proceedings concerning hospitals with which it has contractual relations; and Legal Aid Bureau of Baltimore City. Designated interested parties for all rate applications are: Provider Reimbursement Department of Blue Cross of Maryland, Inc.; Medical Care Programs Administration of the Maryland Department of Health (Medicaid); Division of Provider Reimbursement and Accounting Policy, Bureau of Health Insurance, Social Security Administration, Department of Health, Education and Welfare of the United States (Medicare); and Health Insurance Association of America. A hospital or any other party in a rate review proceeding may be represented by legal counsel at any or all times during the proceeding, but there is no requirement that parties have legal counsel. Any party to a proceeding may challenge the ability of any member of the Commission to consider the rates or issues in that proceeding. Excepting private conferences, this challenge shall be made during the proceeding before its first hearing. Challenges may not be permitted after the first hearing, except in extraordinary circumstances. A challenge shall be verified in writing, specifying the member of the Commission and shall set forth all its reasons. The challenge shall be filed with the Commission and entered upon the record of the proceeding. A copy of the challenge shall be forwarded to the challenged member immediately after it is filed, and he may make whatever response he deems proper and necessary. The challenge shall be denied or allowed by a majority of the Commission, excluding the challenged member. The order based on the decision shall be filed with the Commission, entered in the record of the proceeding and served on the challenged member and the challenging party. If a challenge to a Commission member is allowed, he immediately shall cease all participation in the proceeding in question as a Commission member. The allowance of a challenge to a member of the Commission may not, in itself, disqualify him from serving as a Commission member in other matters and proceedings. When two or more rate proceedings involve common questions of fact, the Commission, upon a majority vote of its members, may order that the common questions of fact be decided in a consolidated proceeding. In proceedings initiated by a regular, temporary, or new hospital rate application, the burden of proof of the reasonableness, equity, and lack of undue discrimination of the proposed rates shall rest with the hospital. In proceedings initiated by an application for an alternative method of rate determination, the burden of proof of the applicability of the alternative method of rate review to the hospital shall rest with the hospital. In proceedings initiated by an order for Commission review of established rates, the burden of proof of the reasonableness, equity, and lack of undue discrimination of the established rates under review shall rest with the hospital. If any section or provision of these regulations is declared unconstitutional or void by any court of competent jurisdiction, or its applicability to any person or circumstances is held invalid, the constitutionality or validity of the remainder of the regulations and the applicability to other persons and circumstances are not affected, and to this end, the sections and provisions of these regulations are declared to be severable. Any interested party may file with the Commission a petition for the promulgation, amendment, or repeal of a regulation designed to implement, interpret, or prescribe law, policy, organization, procedure, or practice requirements of the Commission. The petition shall set forth: The interest of the petitioner and the nature of the relief desired; Any facts, views, arguments, and data deemed relevant by the petitioner; Verification under oath by the party or by a duly authorized officer or agent of the party, whose address and title shall be stated. If the petition is for the promulgation of a regulation, a copy of the proposed regulation shall be attached. If the petition is for the amendment of a regulation, a copy of the amended regulation shall be attached with new matters underlined and matters to be deleted bracketed. In addition to and accompanying the original of the petition filed with the Commission, there shall be 12 copies for use of the Commission and other interested parties. The Commission shall consider the petition as well as all comments relating to it by interested parties. Within 30 days from the filing of the petition, the Commission shall render a decision: Denying the petition and stating the reasons therefor; or Submitting the proposed action to the Maryland Register for notice to, and comments by, all interested parties. An interested person may file with the Commission a petition for a declaratory ruling with respect to the manner in which the Commission would apply a statute that the Commission enforces, a regulation of the Commission, or an order of the Commission, to a person or property on the facts set forth in the petition. The petition for a declaratory ruling shall be filed in writing and shall contain a statement describing in detail the interest of the petitioner in making the request, the issues involved, a statement of the facts, a listing of documents or statements, or both, to be considered, and a sworn statement by the petitioner that the facts contained there are true to the best of the person's knowledge and belief. Sixty days from the receipt of the petition the Commission shall inform the petitioner whether the petition will be granted. If the petition is not granted the Commission shall inform the petitioner in writing of the reasons for the denial. If the petition is granted, the Commission shall inform the petitioner when to expect the declaratory ruling. Consideration. The petition shall be granted whenever the Commission deems issuing a declaratory ruling advisable under the circumstances. In rendering its declaratory ruling, the Commission: Shall consider all the materials submitted with the petition; or May, in its discretion: Consult individuals or materials outside the corners of the petition; or Require argument of the question or permit the introduction of evidence. Disposition. A declaratory ruling issued shall be in writing, stating the: Issue; Conclusion; Facts upon which the conclusion was based; and Sources relied upon. A declaratory relief issued by the Commission shall plainly state on its face that it is a declaratory ruling pursuant to this regulation. A written answer from the Commission to an inquiry may not be construed as a declaratory ruling unless made in conformity with these regulations. Publication and Inspection. The Commission: Shall keep a record of each declaratory ruling issued and index all declaratory rulings issued by reference to statute or statutes or regulation or regulations involved. May publish a declaratory ruling of general interest subject to the mandates of the Public Information Act, State Government Article, §10-601 et seq., Annotated Code of Maryland, and allow inspection of the declaratory rulings subject to the Public Information Act. Denial of a Petition for Declaratory Ruling. A petition may be denied if the: Request contains incomplete information upon which to base an informed declaratory ruling; Commission concludes that a declaratory ruling cannot reasonably be given on the matter; Matter is adequately covered by a prior regulation, declaratory ruling, decision, or legal opinion; or Commission concludes that a declaratory ruling would not be in the public interest. Effect. A declaratory ruling shall be binding upon the Commission and the petitioner on the statement of facts covered in the declaratory ruling and set forth in the petition. After notice and an opportunity to reply, a declaratory ruling may be reconsidered, amended, altered, or revoked by the Commission. Appeal. A declaratory ruling is subject to review as provided in State Government Article, §10-305, Annotated Code of Maryland. Health-General Article, §§15-601 et seq. and 19-201, 19-207, 19-210—19-214, 19-214.1, 19-214.2, 19-214.3, 19-216—19-220, and 19-222; Insurance Article, §§14-501, 14-502, and 14-504; State Government Article, §10-304(b); Annotated Code of Maryland Effective date: November 7, 1974 (1:4 Md. R. 177) Regulation .16 amended effective August 20, 1975 (2:18 Md. R. 1234) Regulation .100 adopted effective December 10, 1975 (2:28 Md. R. 1680) Chapter revised effective October 27, 1976 (3:22 Md. R. 1250) Regulation .01 amended effective November 8, 2004 (31:22 Md. R. 1595) Regulation .01I, J adopted effective January 8, 1990 (16:26 Md. R. 2794) Regulation .01K adopted effective May 12, 2003 (30:9 Md. R. 615) Regulation .01-1 adopted effective October 5, 1998 (25:20 Md. R. 1531) Regulation .02B amended effective December 14, 1987 (14:25 Md. R. 2660) Regulation .03 amended as an emergency provision effective June 15, 1998 (25:14 Md. R. 1127); emergency status expired December 15, 1998 Regulation .03 amended effective August 5, 2002 (29:15 Md. R. 1142); January 15, 2018 (45:1 Md. R. 14) Regulation .03A amended as an emergency provision effective July 1, 2000 (27:17 Md. R. 1616); emergency status extended at 27:26 Md. R. 2356; emergency status extended at 28:7 Md. R. 687; emergency status expired July 1, 2001 Regulation .03A amended effective November 7, 2005 (32:22 Md. R. 1756); October 8, 2007 (34:20 Md. R. 1740); April 11, 2016 (43:7 Md. R. 450); January 16, 2017 (44:1 Md. R. 12); December 13, 2021 (48:25 Md. R. 1080) Regulation .03A amended as an emergency provision effective November 3, 2022 (49:25 Md. R. 1048); emergency provision expired May 1, 2023 Regulation .03A amended effective May 1, 2023 (50:8 Md. R. 338) Regulation .03B amended effective September 1, 2003 (30:17 Md. R. 1203); March 15, 2004 (31:5 Md. R. 449) Regulation .03C adopted effective November 19, 1984 (11:23 Md. R. 1993) Regulation .03C amended effective October 3, 1988 (15:20 Md. R. 2334) Regulation .03D adopted effective January 8, 1990 (16:26 Md. R. 2794) Regulation .03D recodified as .03C effective August 5, 2002 (29:15 Md. R. 1142) Regulation .03D adopted as an emergency provision effective January 1, 2004 (31:4 Md. R. 313); adopted permanently effective May 10, 2004 (31:9 Md. R. 713) Regulation .03D amended as an emergency provision effective July 1, 2009 (36:15 Md. R. 1163); amended permanently effective October 5, 2009 (36:20 Md. R. 1529) Regulation .03-1 adopted effective November 8, 2004 (31:22 Md. R. 1595) Regulation .03-1A amended effective January 15, 2018 (45:1 Md. R. 14) Regulation .03-1B amended effective May 8, 2006 (33:9 Md. R. 796); April 11, 2016 (43:7 Md. R. 450) Regulation .04 amended effective June 15, 1979 (6:12 Md. R. 1050) Regulation .04C adopted effective May 1, 2023 (50:8 Md. R. 338) Regulation .04-1 adopted as an emergency provision effective October 8, 1998 (25:22 Md. R. 1650); adopted permanently effective February 8, 1999 (26:3 Md. R. 175) Regulation .04-1 amended as an emergency provision effective May 21, 2001 (28:13 Md. R. 1214); amended permanently effective September 3, 2001 (28:17 Md. R. 1557) Regulation .04-1 amended effective January 15, 2018 (45:1 Md. R. 14) Regulation .04-2 adopted effective November 13, 2000 (27:22 Md. R. 2060) Regulation .04-2 amended effective April 30, 2001 (28:8 Md. R. 760); January 15, 2018 (45:1 Md. R. 14) Regulation .04-2A, C amended effective January 12, 2009 (36:1 Md. R. 22) Regulation .04-2C amended effective October 9, 2006 (33:20 Md. R. 1617) Regulation .04-3 adopted effective November 13, 2000 (27:22 Md. R. 2060) Regulation .04-3 amended effective April 30, 2001 (28:8 Md. R. 760); January 15, 2018 (45:1 Md. R. 14) Regulation .05 amended as an emergency provision effective July 1, 2000 (27:17 Md. R. 1617); amended permanently effective November 13, 2000 (27:22 Md. R. 2060) Regulation .05 amended effective September 3, 2001 (28:17 Md. R. 1557) Regulation .05F amended as an emergency provision effective November 3, 2022 (49:25 Md. R. 1048); emergency provision expired May 1, 2023 Regulation .05F amended effective May 1, 2023 (50:8 Md. R. 338) Regulation .06E adopted effective August 28, 1995 (22:17 Md. R. 1318) Regulation .06E amended effective September 9, 1996 (23:18 Md. R. 1317); November 4, 1996 (23:22 Md. R. 1497); February 9, 1998 (25:3 Md. R. 146) Regulation .06E recodified to .06F and new .06E adopted effective October 5, 1998 (25:20 Md. R. 1531) Regulation .06F amended effective March 4, 2013 (40:4 Md. R. 346) Regulation .06G adopted effective October 9, 2006 (33:20 Md. R. 1617) Regulation .07 amended effective August 31, 1977 (4:18 Md. R. 1398) Regulation .07-1 adopted effective September 10, 2007 (34:18 Md. R. 1580) Regulation .07-1A amended effective December 13, 2021 (48:25 Md. R. 1080) Regulation .07-1C amended effective December 21, 2015 (42:25 Md. R. 1544); May 9, 2016 (43:9 Md. R. 530) Regulation .07-1E amended effective May 14, 2012 (39:9 Md. R. 612) Regulation .07-1K, L adopted effective December 13, 2021 (48:25 Md. R. 1080) Regulation .07-2 adopted effective January 16, 2017 (44:1 Md. R. 12) Regulation .10C amended effective April 9, 1984 (11:7 Md. R. 626); March 8, 1999 (26:5 Md. R. 391); December 21, 2015 (42:25 Md. R. 1544) Regulations .11C and .12B amended effective May 29, 1981 (8:11 Md. R. 975) Regulation .11G adopted effective January 15, 2018 (45:1 Md. R. 14) Regulation .13B amended effective September 19, 1980 (7:19 Md. R. 1806) Regulation .13H adopted effective July 28, 1978 (5:15 Md. R. 1190) (originally codified as Regulation .12G) Regulation .14I amended effective December 12, 2002 (29:24 Md. R. 1919) Regulation .20 amended effective April 9, 1984 (11:7 Md. R. 626); March 8, 1999 (26:5 Md. R. 391) Regulation .23 amended effective May 11, 1977 (4:10 Md. R. 767) Regulation .25I adopted effective May 9, 1983 (10:9 Md. R. 791) Regulation .26 amended as an emergency provision effective June 19, 2009 (36:15 Md. R. 1163); amended permanently effective October 5, 2009 (36:20 Md. R. 1530) Regulation .26 amended effective November 15, 2010 (37:23 Md. R. 1611); December 11, 2025 (52:24 Md. R. 1198) Regulation .26A amended effective July 1, 1988 (15:13 Md. R. 1555); April 3, 1989 (16:6 Md. R. 728); November 26, 1990 (17:23 Md. R. 2732); March 30, 1992 (19:6 Md. R. 674); June 7, 1993 (20:11 Md. R. 913); July 5, 1993 (20:13 Md. R. 1049); August 1, 1994 (21:15 Md. R. 1306) Regulation .26A amended as an emergency provision effective June 1, 1996 (23:13 Md. R. 938); emergency status expired November 13, 1996 Regulation .26A amended December 30, 1996 (23:26 Md. R. 1860) Regulation .26A amended as an emergency provision effective November 24, 1997 (24:26 Md. R. 1752); emergency status extended to August 31, 1998 (25:12 Md. R. 943); emergency status extended to October 31, 1998 (25:18 Md. R. 1431) Regulation .26A amended October 5, 1998 (25:20 Md. R. 1531) Regulation .26A amended as an emergency provision effective February 25, 1999 (26:6 Md. R. 480); amended permanently effective June 28, 1999 (26:13 Md. R. 1020) Regulation .26A amended as an emergency provision effective June 26, 2000 (27:15 Md. R. 1397); amended permanently effective November 13, 2000 (27:22 Md. R. 2060) Regulation .26A amended as an emergency provision effective December 6, 2000 (28:3 Md. R. 203); amended permanently effective April 30, 2001 (28:8 Md. R. 760) Regulation .26A amended effective October 29, 2001 (28:21 Md. R. 1856); May 13, 2002 (29:9 Md. R. 745) Regulation .26A repealed effective September 1, 2003 (30:17 Md. R. 1203) Regulation .26A amended effective November 15, 2010 (37:23 Md. R. 1611); August 6, 2012 (39:15 Md. R. 963); May 6, 2019 (46:9 Md. R. 445); April 5, 2021 (48:7 Md. R. 259) Regulation .26A-2 amended effective December 10, 2012 (39:24 Md. R. 1577); April 5, 2021 (48:7 Md. R. 259) Regulation .26A-3 adopted effective April 5, 2021 (48:7 Md. R. 259) Regulation .26B amended effective October 3, 1988 (15:20 Md. R. 2334); May 29, 1989 (16:10 Md. R. 1109); May 14, 1990 (17:9 Md. R. 1092); August 1, 1994 (21:15 Md. R. 1306); March 11, 1996 (23:5 Md. R. 380); September 30, 2002 (29:19 Md. R. 1524); April 10, 2006 (33:7 Md. R. 673); April 5, 2010 (37:7 Md. R. 572); August 4, 2014 (41:15 Md. R. 891) Regulation .26C adopted as an emergency provision effective April 7, 1998 (25:9 Md. R. 677); emergency status expired July 22, 1998; adopted permanently effective September 7, 1998 (25:18 Md. R. 1435) Regulation .26-1 adopted effective May 12, 2003 (30:9 Md. R. 615) Regulation .26-1 amended as an emergency provision effective June 12, 2008 (35:14 Md. R. 1244); amended permanently effective October 6, 2008 (35:20 Md. R. 1775) Regulation .26-1B amended as an emergency provision effective March 21, 2014 (41:8 Md. R. 468); emergency status extended to August 1, 2014 (41:15 Md. R. 888); amended permanently effective July 7, 2014 (41:13 Md. R. 753) Regulation .26-1 amended as an emergency provision effective July 1, 2015 (42:16 Md. R. 1053); amended permanently effective November 9, 2015 (42:22 Md. R. 1378) Regulation .26-2 adopted effective March 9, 2009 (36:5 Md. R. 423) Regulation .27A amended effective February 18, 2002 (29:3 Md. R. 221) Regulation .100 recodified as Regulation .33 Regulation .34 adopted effective August 1, 1987 (14:15 Md. R. 1660) Regulation .35 adopted effective August 1, 1987 (14:15 Md. R. 1660) Regulation .36 adopted effective August 1, 1987 (14:15 Md. R. 1660)