Discount Contract List

Budgeted Discounts for FY 2015

Hospital Name: Charleston Area IWedical Center, Inc.
Budgeted total
nongovt'I. utilzation

+507,qadi,5'~
Enter budgeted total gross patient revenues from the B-5:
Enter budgeted total operating expenses from the B-5: $ 903,248,000

6,488
249,768

Inpatient:
Outpatient:

/r

*Note: Utilization must match the total (acute and DPU) discharges and visits on Form B-1.
Volume threshold equals 5% of nongovernmental
utilization. To calculate contract utilization combine total inpatient
and outpatient utilization on a one-to-one basis and compare to threshold.

Contract List for Too Section

> Contracts

with volumes

less than volume

threshold above;
W

Contracts with current approvals;

> Third-party
W Non-HMO

or Risk Contracts.

Name of Third Partv Pavor

State BC/BS OP (Lab)
2 innovative Resources Group FRC
3 DirectCare Amedca

> If "Must Separate" appears in either column,

contract must be reported in lower section of this
adam:
form and separately
on Form B-DC.

Inoatient %
P PP%
P OP%

2.00%
3 00%
1.00%

-.

P OP%

7 USA Managed Care

8 HealthSmart

9 Stratose
10 Prime
11 Health. Plan Payors Organization,
12 United HealthCare

Outout Onlv (Do Not Enter Anvthina)

Do not change form template.

Discounts must be in percentages not
decimals (e.g. 10% - not 0.10).
W Percentages for I/P and 0/P must
be input to receive approval of that
portion of contract.

Contracts (only); and,

1 Mountain

4 MultiPlan
5 CIGNA
6 ThreeRivers

Enterina Discount Percentaaes

W

Ltd.

1.00%
2.00%
2.00%
2 00%
3 00%
1.00%

Outoatient

15.00%
15.00%
2 00%
3 00%
PP%
P PP%
1 PP%
1

2.00%
2 00%
2.00%
3.00%
1 00%

13
14
15
16
17
18

4AI

> Columns

will

indicate if contract reimburses

cost + 10% margin.

Inaatient

. :IIS.- -
ma
I

IS

lnk11s 5 K=.
~

....*I
I

~ns

4411411

i'lian
!0 Snl

Irm:

Outaatient

lf

'Il 4 III

~ 4II!!
arm~i i~

Ijl

s'
r

ssn

"-

II!'lI!s

11

s 44!10I

S !'

e 4I

'

t!

'I

In

II

:-

10!i,'r

19

I'II+/Iso

20

~I

01'~

List discounts in lower section that are: (1) new or not currently approved contracts; (2) non-third party (e.g. admin. adj.); (3)
contracts with utilization > calculated volume threshold above*; (4) HMO or risk contracts'or, (5) top section of template
determined that it must be separated.
1 Aetna

2 MSBC/BS (Td & PPO)

3 Carelink
4 The Health
5
6
7
8
'

10

Plan

2.00%
6 PP%
2.00%
2 00%

2.00%
6 PP%
2.00%
2.00%

Must
Must
Must
Must
Must
Must
Must
Must
Must
Must

Separate
Separate
Separate
Separate
Separate
Separate
Separate
Separate
Separate
Separate

Must
Must
Must
Must
Must
Must
Must
Must
Must
Must

Separate
Separate
Separate
Separate
Separate
Separate
Separate
Separate
Separate
Separate

5M-DC

Summary Information of Discount Contracts

Total - FY 2015 8udgeted
Hospi Charleston Area Medical Center, Inc.
1

Name of Purchaser or Third Party Payor

Date of Contract
Date Contract Expires
Budgeted Inpatient Discharges
Budgeted Gross Inpatient Revenue
Inpatient Discount Percent
Budgeted Amount of Inpatient Discount
Budgeted Net Inpatient Revenue
Budgeted Inpatient Cost
Budgeted Inpatient Charge per Discharge
Budgeted Inpatient Cost per Discharge

3
4
5

6
7
8

9
10

11
12 Budgeted Cost to Charge Ratio

13 Budgeted Outpatient

23
24

INSBCBS Td8PPO

5,466
$ 199,182,310

1,291
$47,042,655

$9,684,996
$ 189,497,314
$ 71,733,815

$45,631,376
$ 16,942,012

'122,926,695

30,838
$33,167,098

$ 1,411,280

$ 10,333,851
$ 194,668,'056
$74,909,858

Budgeted Cost to Charge Ratio

12 31 15
11 1 14

Aetna

Carelink

10/26/2007
12/31/2015 AUTO
3,589
$ 130,773,079

$995,013
$32,172,085
$ 12,119,607

478
$ 17,426,667

36.01%

36.01%

137,191
$ 147,553,536
6%
$8,853,212
$ 138,700,324
$53,917,618
$ 1,075.53
$393.01

19,579
$21,057,761
2%
$421,155

509
$547,446
2%
$ 10,S4S
$536,497
$200,043
$ 1,075.53
$393.01

$7,694,728
$ 1,075.53
$393.01
36.01%

36.01%

71.S0%

71.90'/o

No

~es

No

~es

No

~ebs

No

Is the Discount Amount Below Actual Cost of Service?

Cost Be ShiRed to Any Other Purchaser of Third Party

Payor as a Result of this Contract?

17
$627,000
2%
$ 12,540
*
$614,460
$225,809
$36,437.04
$ 13,122
36 01%

'20,636,606

71.90'/o

Circle

AUTO

$47,096,812
$36,437.04
$ 13,122

36.01'/0

36.01o/o

Budgeted Medicare, Medicaid 8 Uncompensated Care

Percent of Gross Patient Revenue After New Discount
Contract (Attach Explanation for anY Difference)
Will Contract(s) Provide a Quantifiable Economic Benefit to
the Hospital?
Circle

12/30/2008

2/1/2008

$348,533
$ 17,078,133
$6,276,066
$36,437.04
$ 13,122

$7,846,385

36.01%

Budgeted Gross Outpatient Revenue

Outpatient Discount Percent
Budgeted Amount of Outpatient Discount
Budgeted Net Outpatient Revenue
Budgeted Outpatient Cost
19 Budgeted Outpatient Charge Per Visit
20 Budgeted Outpatient Cost Per Visit

22

Combined Contracts

190,605
$205,001,906

Visits

14
15
16
17
18

21

Total

Fiscal Year Ending:

Submission Date:

No

~Yes

No

Yes'o

~Yes

No

Will

25

Circle

26 Date contract submitted to

Yes

CNN,

Yes

Any Changes to the Contracts

Yes

~o

Yes

~N
5/1/2000

11/2/2001

Since Submission to the

27 Authority? (If yes, please submit revised contracts.)

Circle

Yes

/Nod

NOTE: This page should include only the total, combined and 3 (three) separate contract columns.
modifications will be returned.

HCA - May 2002

~No
11/2/2007

HCA

Dona

'IK

Yes

( No

Use this form

in its

Yes

CNob

Yes

current version only. Any

ANo

. 3M-DC

Summary Information of Discount Contracts

Total - FY 2015 Budgeted
Hospi Charleston Area IIedical Center, Inc.
1

Fiscal Year Ending:

Submission Date:

Name of Purchaser or Third Party Payor

Date of Contract

1/1/2011

Date Contract Expires

4 Budgeted Inpatient Discharges
5 Budgeted Gross Inpatient Revenue
6 Inpatient Discount Percent
7 Budgeted Amount of Inpatient Discount
8 Budgeted Net Inpatient Revenue
9 Budgeted Inpatient Cost
10 Budgeted Inpatient Charge per Discharge
11 Budgeted Inpatient Cost per Discharge

AUTO

91
$3,312,909
2%
$66,258
$3,246,651

$ 1,193,116
$36,437.04
$ 13,122.49
36 01%

12 Budgeted Cost to Charge Ratio

13 Budgeted Outpatient Visits

2,488
$2,676,065
2%
$ 53,521
$2,622,544
$977,862
$ 1,075.53
$393.01

14 Budgeted Gross Outpatient Revenue

21

23

Outpatient

Budgeted
Budgeted
Budgeted
Budgeted
Budgeted

11 1 14

The Health Plan

15
16
17
18
19
20

123115

Discount Percent
Amount of Outpatient

Discount
Revenue
Outpatient Cost
Outpatient Charge Per Visit
Net Outpatient

Outpatient Cost Per Visit

Budgeted Cost to Charge Ratio

36.01%

Budgeted Medicare, Medicaid & Uncompensated Care

Percent of Gross Patient Revenue After New Discount
Contract (Attach Explanation for any Difference)
Will Contract Provide a Quantifiable Economic Benefit to the
Hospital?
Circle

71 90%

No

Yes

No

Yes

No

Yes

No

Yes

No

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Is the Discount Amount Below Actual Cost of Service?

Circle

25

Cost Be Shifted to Any Other Purchaser of Third Party

Payor as a Result of this Contract?

26

Date contract submitted to HCA

Yes

Will

Circle

Yes

No

11/23/2010

Any Changes to the Contracts Since Submission to the

27 Authority? (If yes, please submit revised contracts.)

Circle

Yes

NOTE: Put no more than 5 (five) contracts on this page. Use this form

o
in its

current version only. Any modifications

will

be returned.