Chapter 6

COL12010610GCA HEALTH ANDSAFETY CH.6GUAM MEDICAL ASSISTANCE PLAN 1CHAPTER 6 GUAM MEDICAL ASSISTANCE PLAN NOTE: This Chapter was taken from P .L. 14 -94, as amended by P .L. 14 -101. § 6101. Statement of Policy . § 6102. Responsibility . § 6103. Plan. § 6104. Program A vailability . § 6105. Title. § 6101. S tatement of Policy. The Legislature declares that medicaid recipients receiving medi cal assistance under Title XIX [federal law] and those persons enrolled under the Medicaid Program of the Social Security Act whose premium s are being paid for by the government of Guam sha ll be given the opportu nity to be enrolled in prepaid health plans as a means of afford ing them com - prehensive health care and related remedial and preventive services. Prepaid Health Plan (PHP) as used herein means a multi -specialty group practice or an individual practice association developed to provide medical services on a prepaid basis. The Department of Public Health and Social Services shall contract with a qualified Prepaid Health Plan pursu ant to this Chapter and shall award such contract o n a non -bid basis.

a prepaid basis. The Department of Public Health and Social Services shall contract with a qualified Prepaid Health Plan pursu ant to this Chapter and shall award such contract o n a non -bid basis. Each Prepaid Health Plan shall furnish to the Depart ment such information and reports as the Department may find necessary in performing its functions under this Chapter . Such information and reports shall include, but shall not be l imited to, statistical information regarding utilization of services, age and sex, specific mortality and morbidity rates, services supplied, manpower resources and costs of health care and administration, compiled from a basic data system as the Departmen t may require. The Prepaid Health Plan and the Department shall maintain such records and afford access thereto to verify the infor mation and reports which may be re quired under this Chapter. The Department shall annually conduct a survey of beneficiarie s to determine their satisfaction with the services provided by the Prepaid Health Plan. All health care services available under this Chapter shall be equivalent to the level and basic scope of services required under public assistance programs.

ices provided by the Prepaid Health Plan. All health care services available under this Chapter shall be equivalent to the level and basic scope of services required under public assistance programs. It is the objec tive of this legislation that health care, as provided COL12010610GCA HEALTH ANDSAFETY CH.6GUAM MEDICAL ASSISTANCE PLAN 2in Guam under Title XIX of the Social Security Act, be available and accessible at all times to all quali fied recipi ents. It is further the intent of this Chapter such care shall be of the highest quality . SOURCE: GC§ 9940, as amended by P .L. 14 -101. § 6102. Responsibility. The Department shall, in carrying out the intent of this Chapter, contract with a multispecialty group practice of an individual practice association through a Prepai d Health Plan to establish pilot program s which demonstrate the value or lack thereof of such a program in delivering or financing health care services in such a manner . Each pilot program be for a specified duration not to exceed four (4) years and each p ilot program shall be evaluated annually for its efficiency , effectiveness and quality .

ces in such a manner . Each pilot program be for a specified duration not to exceed four (4) years and each p ilot program shall be evaluated annually for its efficiency , effectiveness and quality . The Department shall pursue the feasibility of establishing the follow ing as pilot program: A per person risk assuming contract with one (1) or more organization which provide payment to a specified class or classes of providers. Persons eligible for services under the public assis tance program shall be assigned by the Depart ment to a Prepaid Health Plan which affords any qualified medicaid provider within the territo ry of Guam an opportunity to participate in the plan under reasonable restrictions approved by the Department; provided, however, such persons shall be entitled to request and receive a medicaid card if assignment to a plan does not meet with their satisfa ction. For purposes of this Section 'risk assuming' means the pilot program contractor agrees to assume the risk of utilization of services or costs of services, or both. The Department shall establish, through contracts, health service delivery system s as pilot programs to determine whether high -quality

risk of utilization of services or costs of services, or both. The Department shall establish, through contracts, health service delivery system s as pilot programs to determine whether high -quality comprehensive medicaid benefits can be provided at a reasonable cost on a prepay ment basis on such a system. The pilot programs shall have at least the following characteristics: The programs shall be operated either by the Depart ment directly or through contracts with Prepaid Health Plans. The programs shall enroll medicaid recipi ents and be funded by the Department on a prepayment capita tion basis. Such rate of COL12010610GCA HEALTH ANDSAFETY CH.6GUAM MEDICAL ASSISTANCE PLAN 3payment shall be determined annually and shall be ten percent (10%) less than valid claims incurred by the Department for cov ered medic - aid recipi ents projected on an annual basis as reflected by the accrued average monthly claims for the previ ous six (6) months plus all anticipated increa ses in costs in the contract year . The rate shall not include any costs of the Department for claims or administra tive fees to fiscal interme diaries.

ous six (6) months plus all anticipated increa ses in costs in the contract year . The rate shall not include any costs of the Department for claims or administra tive fees to fiscal interme diaries. The per capita amounts determined shall be based on sound actuarial data and be recognized to vary betwe en the categories of aid to families with dependent children, aid to the totally disabled, aid to the blind, old age security or such other categories as may be determined by the Director of the Department. The programs shall provide the full range of serv ices offered under the public assis tance program and shall meet all statutory requirements and all regulatory and contractu al requirements established by the Department for the program. The programs shall emphasize the innova tive use of health personnel including mid -level medical, nursing and dental profes - sionals in ambulatory set tings. Medicaid recipients enrolling in a pilot program pursuant to this Chapter shall be offered a choice of qualified primary care physicians employed or under contractual arrangements with the Prepaid Health Plan to be the recipients' designated primary care physi cians. SOURCE: GC § 9941.

red a choice of qualified primary care physicians employed or under contractual arrangements with the Prepaid Health Plan to be the recipients' designated primary care physi cians. SOURCE: GC § 9941. § 6103. Plan. Prepaid Health Plans contract ing under this Chapter shall guarantee and provide assurances to the Depart ment that all services contracted for shall be readily available and accessible and that further , all medical services covered under the contract which are required on an emergency basis be available on a 24 -hour, seven days a week basis, either in the Prepaid Health P lans own facilities or through arrangements with another provider which has been approved by the Department. The Depart ment is hereby directed to establish standards of care and to conduct testing and review proce dures to assure compli ance with such sta ndards. It is in the public interest that medical assis tance of the proper quality and quantity be provided in the most effective and economical manner consistent with such high quality medical standards. It is further the COL12010610GCA HEALTH ANDSAFETY CH.6GUAM MEDICAL ASSISTANCE PLAN 4objective of this Chapter that there shall be proper

al manner consistent with such high quality medical standards. It is further the COL12010610GCA HEALTH ANDSAFETY CH.6GUAM MEDICAL ASSISTANCE PLAN 4objective of this Chapter that there shall be proper utilization of all health care services. All administrative powers and duties with respect to Prepaid Health Plans, including deter mination of per capita payment rates, approval of prepaid health contracts and pilot programs which provide health care services pursuant to prepaid health contracts is hereby vested with the Director of the Department of Public Health and Social Services herein referred to as Director . The Director is hereby empowered to establish a basic schedule of benefits for prepaid plans conforming to the scope and duration of medic aid health services as set forth in Federal require ments for the territory of Guam to enumerate standards of participation for such Prepaid Health Plans and pilot programs. In the administration of this Chapter and in the negotiating of c ontracts thereunder, the Department shall give due consider ation to the reputation of the prepaid health organization in providing such benefits, to the accessibility and availability of its facili

ontracts thereunder, the Department shall give due consider ation to the reputation of the prepaid health organization in providing such benefits, to the accessibility and availability of its facili ties and resources for health care to enrolled persons under this Chap ter, and to new and innovative concepts in the delivery of health care services. No contract between the Director and a Prepaid Health Plan shall be approved unless the plan and its f acilities meet quality program standards. These standards shall require the Prepaid Health Plan to demonstrate to the Department that it has adequate financial resourc es, physical facilities, organiza tional and administrative capacities, and a sound pro gram design to discharge its contractual obligations. The Prepaid Health Plan will maintain financial records in accordance with applicable Federal guidelines and will also have annual audits performed by an independent certified public accountant. Ce rtified financial statements shall be filed annually as soon as practical after the close of the plan's fiscal year and in any event within a period not to exceed one hundred twenty (120) days thereafter.

ed financial statements shall be filed annually as soon as practical after the close of the plan's fiscal year and in any event within a period not to exceed one hundred twenty (120) days thereafter. For good cause, the Department may grant exceptions to the time within which annual financial statements are to be submitted to the Depart ment. The Prepaid Health Plan shall be liable for all valid out -of-area emergency services which are required by the contract and rendered by another provider . Payment f or such services shall cover treatment of emergency conditions provided plan has been notified within seventy -two COL12010610GCA HEALTH ANDSAFETY CH.6GUAM MEDICAL ASSISTANCE PLAN 5(72) hours of occurrence until such time as the patient may reasonably be transferred to the Prepaid Health Plan's facilities. The Prepaid Health Plan shall establish proce dures for continuously reviewing the quality of care, the utilization of services and facilities and costs. Information derived from such review shall be made available to the Depart ment. If the enrollee has an unresolv ed grievance, a fair hearing shall be made available under appro priate provi sions of the Government Code of

m such review shall be made available to the Depart ment. If the enrollee has an unresolv ed grievance, a fair hearing shall be made available under appro priate provi sions of the Government Code of Guam to resolve all grievances regarding care and administration of the plan. Findings and recommenda tions of the Director based on the results o f the fair hearing shall be binding on the plan and the enrollees. The Director shall report annually to the Legislature on the experience with the prepaid plan with specific reference to consumer satisfac tion and dissatisfaction, quality and utilizatio n. SOURCE: GC§ 9942. § 6104. Program Availability. Any provider of medical assistance under the Guam Medical Assistance Plan which has entered into a con tract with the Department of Public Health and Social Services pursuant to this Chapter, may make t he benefits known to enrollees by means of relevant methods and materials. The materials may be disseminated to enrollees by the Depart ment at the contractor's expense. The contrac tor shall be responsible for all presentations by such representatives and for all ethical and professional content of the plans materials.

by the Depart ment at the contractor's expense. The contrac tor shall be responsible for all presentations by such representatives and for all ethical and professional content of the plans materials. Examples of all printed or illustrated m aterial prepared by the contractor shall be submitted prior to dissemination. SOURCE: GC§ 9943. § 6105. Title. This Chapter may be cited as the Guam Medical Assistance Plan. SOURCE: GC§ 9945. ----------COL120106