(A) The department shall issue a certificate of public advantage for a cooperative agreement if it determines that:

1. (1) the applicants have demonstrated that the likely benefits resulting from the agreement outweigh the likely disadvantages from the agreement;

   1. (a) in evaluating the benefits likely to result from the cooperative agreement, the department shall consider, but is not limited to:

      1. (i) enhancement of the quality of health and health related care provided to South Carolina citizens;
      2. (ii) preservation of health care providers close to communities traditionally served by those providers;
      3. (iii) gains in the cost-efficiency of the services offered by the health care providers or purchasers involved;
      4. (iv) improvements in the use of health care provider resources and equipment;
      5. (v) avoidance or elimination or reduction of duplication of health care resources;
      6. (vi) improvement in access to health care for citizens in the community;
      7. (vii) support of the agreement by purchasers and payers in the health service area;
      8. (viii) the extent of financial risk-sharing by the parties as a result of the agreement;
      9. (ix) the provision or enhancement of health care services to Medicaid, indigent, or charity care patients by the parties to the agreement.

   2. (b) In evaluating the disadvantages likely to result from the agreement, the department shall consider, but is not limited to:

      1. (i) the likely adverse impact, if any, on the ability of the health care purchasers to negotiate optimal payment and service arrangements with the health care providers or health provider networks;
      2. (ii) the extent of any reduction in competition among health care providers, purchasers, or other persons furnishing goods or services to or in competition with health care providers or purchasers that is likely to result directly or indirectly from the health care cooperative agreement;
      3. (iii) the likely adverse impact, if any, on patients in the quality, availability, and price of health care services;
      4. (iv) the extent to which the agreement may increase the costs of prices of health care at a hospital or other health care provider which is a party to the agreement;
      5. (v) the extent to which services to Medicaid, indigent, or charity care patients are adversely impacted by the agreement; and

2. (2) reduction in competition likely to result from the agreement is reasonably necessary to obtain the benefits likely to result. In evaluating whether the reduction in competition is necessary to obtain the likely benefits, the department shall consider, but is not limited to:

   1. (a) the availability of arrangements that:

      1. (i) are less restrictive to competition and achieve the same benefits;
      2. (ii) offer a more favorable balance of benefits over disadvantages attributable to a reduction in competition likely to result from the agreement.
   2. (b) the ease with which health care providers or health care purchasers may obtain contracts with other health plans;
   3. (c) the difficulty in establishing new competing health plans in the relevant geographic market, including the ability to offer services requiring a certificate of need or purchasing these services from another health care provider or health provider network; and
   4. (d) the sufficiency of the number or type of providers under contract with the health plan available to meet the needs of plan enrollees.