Chapter 9

10 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 1 CHAPTER 9 CONSUMER HEALTH PROTECTION ACT AG OPINION: Portions of this Chapter [Articles 1-5] are unenfor ceable because of violations of federal law (ERISA). See AG Opinio n GHPDA #86-1021. Article 1. General Provisions. Article 2. Administration. Article 3. Standards of Participation. Article 4. Benefits. Article 5. Consumer Health Protection Premium. Article 6. Maternal and Child Health Crippled child ren. [Repealed] Article 7. Maternal and Child Health Services. [Rep ealed] Article 8. Services for Crippled Children. [Repeale d] Article 9. Health Care Prompt Payment Act of 2000 ARTICLE 1 GENERAL PROVISIONS § 9101. Legislative Intent. § 9102. Definitions. § 9101. Legislative Intent . The Legislature hereby finds and declares that the cost of health care now exceeds the ability to pay for the average resi dent of Guam. Expanded insurance protection has been seriously retarded by uncontrolled inflation in health care costs. Factors responsible for the inflationary spiral i n health costs include failure to place primary emphasis on personal disea se prevention, and personal maintenance of health and ambulatory healt h

. Factors responsible for the inflationary spiral i n health costs include failure to place primary emphasis on personal disea se prevention, and personal maintenance of health and ambulatory healt h care. To improve this situation, it is necessary to strengthen the planni ng of operating health services, guarantee quality and accessibility of ap propriate health care at all times and require the accountability of the provide r to make available that care plus development of standards of quality suffi cient to adequately protect patients. To assure that citizens of the Territory will be ab le to obtain as well as afford necessary health services on an equitable ba sis, compulsory prepaid health and sickness coverage, accomplished through payroll deduction made by employers and employees, is effective on the pas sage of this Chapter, and COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 2 operative on the first day of the first calendar ye ar after the rates and benefits proposed by the Commission have been approved by th e Legislature. SOURCE: GC § 9990. § 9102. Definitions.

ON ACT 2 operative on the first day of the first calendar ye ar after the rates and benefits proposed by the Commission have been approved by th e Legislature. SOURCE: GC § 9990. § 9102. Definitions. (a) Prepaid Health Plan means a plan which offers a specified scope of benefits to an enrolled population for a predetermi ned prepaid annual rate. (b) Health Maintenance Organization means any organization of providers of personal health services with a proven capacity to provide preventive and health maintenance services to a giv en population of enrolled consumers in a Prepaid Health Plan. Providers shall guarantee that quality services be available and accessible twenty-four (2 4) hours a day, seven (7) days a week. The definition of health maintenance o rganization under this Subdivision shall include, but not be limited to, ' medical care foundations,' group practice prepayment organizations and health consumer organizations. Medical care foundation means any non-profit founda tion whose physician membership is capable and guarantees to provide com prehensive health services to patients enrolled in a Prepaid Health P lan.

Medical care foundation means any non-profit founda tion whose physician membership is capable and guarantees to provide com prehensive health services to patients enrolled in a Prepaid Health P lan. Health consumer organization means any incorporated organization of citizens whose primary motive for organizing is to create a system of fina ncing and arranging for the delivery of personal health services under circumst ances which require sensitivity to the consumer's desires in this field . A group practice prepayment organization means a formal, organized g roup of doctors and other providers in a group practice center with cen tralized management peer review, and a formal structure and organization. (c) Fiscal Intermediary means any private insurance company which performs fiscal and administrative functions for an y organization or provider of health care, or on behalf of consumers through a contract for health benefits. (d) Peer Review-Medical Audit means an organized system for regular review of professional performance in or out of the hospital by a committee of peers. Such review is designed to judge the medi cal justification for case management to assure its quality.

or regular review of professional performance in or out of the hospital by a committee of peers. Such review is designed to judge the medi cal justification for case management to assure its quality. (e) Utilization Review means an organized review by peers designed to control or eliminate unnecessary admissions to hosp itals, and unwarranted length of stays in hospitals. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 3 (f) Provider Profiles means computer-assisted files of the performance of a provider over an extended period of time. (g) Provider means any licensed individual or organization enga ged in the providing of personal health service to the pub lic. (h) Health Commission means that body under which this legislation assumes powers and responsibility for activities re lated to providing personal health care to the public. (i) Approved Hospital means a licensed hospital which meets the standards of performance as developed by the Health Commission to assure quality of care, safety of the patient and such oth er criteria as the Commission deems necessary.

ed hospital which meets the standards of performance as developed by the Health Commission to assure quality of care, safety of the patient and such oth er criteria as the Commission deems necessary. (j) Health Facility means any licensed facility whose primary function is to deliver personal health service to the public . This includes, but is not limited to, out-patient clinics, hospitals, clinics , nursing homes, home care organizations and intermediate care facilities. (k) Prepaid Capitation means an annual fixed premium per person paid in advance for a specified set of comprehensive hea lth benefits. (l) Benefit Period means the period of time during which an enrolled person is covered under a Prepaid Health Plan. (m) Allied Health Professional means any professional person involved in the provision of skilled health service both dir ectly or indirectly in support of physicians and health institutions engaged in th e delivery of health care services. (n) Out of Area Emergency Services means medical treatment for any sudden or unexpected illness, or the medical treatm ent of an injury or injuries.

engaged in th e delivery of health care services. (n) Out of Area Emergency Services means medical treatment for any sudden or unexpected illness, or the medical treatm ent of an injury or injuries. Such illnesses or injuries shall be those requiring medical services at a location outside the area of the patient's own health maintenance organization, and requiring the medical services of another provider of health care services, so as to not compromise the q uality of care or safety of the patient by delaying treatment. This shall inclu de any emergency services provided to an enrollee while off-island. (o) Enrollee means a person who has enrolled as a beneficiary o f a health benefit plan. SOURCE: GC § 9990.1. ---------- COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 4 ARTICLE 2 ADMINISTRATION § 9201. Administration: Health Commission Created. § 9202. Same: Contracts Executed After This Act. § 9201. Administration: Health Commission Created. The Health Commission is hereby created and is the regulatory body which shall set policy and determine regulations wh ich relate to the operation of personal health service of all kinds.

on Created. The Health Commission is hereby created and is the regulatory body which shall set policy and determine regulations wh ich relate to the operation of personal health service of all kinds. The Health Commission shall consist of seven (7) members, appointed by th e Governor with the advice and consent of the Legislature, four (4) mem bers of the initial com- mission to be appointed for one (1) year, three (3) members to be appointed for two-year terms. The Commission shall choose fro m its membership, a chairman. The Director of Public Health and Social Services shall be the Chief Administrative Officer and shall carry out th e decisions, policies and regulations of the Commission. (a) Compensation of Members. Members of the Commiss ion shall be paid at the rate of Fifty Dollars ($50) per day for each day on which the Commission meets, such compensation not to exceed O ne Hundred Dollars ($100) per month. SOURCE: GC § 9990.2, as amended by P.L. 15-148. § 9202. Same: Contracts Executed After This Act. Notwithstanding any other provisions of law, no con tract for provision of health care services executed after the operativ e date of this Chapter between individuals and

cts Executed After This Act. Notwithstanding any other provisions of law, no con tract for provision of health care services executed after the operativ e date of this Chapter between individuals and fiscal intermediaries or gr oups of any type and fiscal intermediaries, may be issued or renewed wit hout approval of the Commission and in compliance with the standards as set forth in Subchapter 3, but all such existing benefit coverage shall rem ain in full force and effect until its date of expiration, provided that such ti me period does not exceed a date four (4) years from the effective date of this Chapter, except that existing programs may be renewed if, the Commission has not been established and has not developed 'standards' as re quired. SOURCE: GC § 9990.3. ---------- ARTICLE 3 STANDARDS OF PARTICIPATION COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 5 § 9301. Standards of Participation: Application of Act. § 9302. Same: Annual Report and Monthly Lists. § 9303. Same: Laboratory Services. § 9304. Same: Certification. § 9305. Same: Availability of Services. § 9306. Same: Liability for Fees. § 9307. Same: Employment of Health Professionals. § 9308.

ts. § 9303. Same: Laboratory Services. § 9304. Same: Certification. § 9305. Same: Availability of Services. § 9306. Same: Liability for Fees. § 9307. Same: Employment of Health Professionals. § 9308. Same: Ratio of Physicians and Health Profes sionals. § 9309. Same: Standards of Care. § 9310. Same: Open Enrollment. § 9311. Same: Booklet. § 9312. Same: Enrollee Grievance Procedure. § 9313. Same: Peer Review. § 9314. Same: Ground for Disenrollment. § 9315. Same: Enrollee Advisory Boards. § 9316. Same: Emergency Services. § 9301. Standards of Participation: Application of Act. The provisions of this Chapter shall apply to heal th maintenance organizations, as defined in Subdivision (b) of § 9 102, engaged in the delivery of health care services under this Chapter . SOURCE: GC § 9990.4. § 9302. Same: Annual Report and Monthly Lists. Each health maintenance organization shall be requ ired to report annually to the Commission on the cost of operation , the use of services, the current description of the location of physicians, allied health professional and health facilities and the number of persons to whom service is rendered.

cost of operation , the use of services, the current description of the location of physicians, allied health professional and health facilities and the number of persons to whom service is rendered. Full fiscal disclosure by any and all providers of service shall be a condition of participation under this Chapter. Each health maintenance organization shall be req uired to furnish complete lists monthly to the Commission or to the agency designated by the Commission of those persons eligible to receive ben efits under Title XVIII or XIX of the Social Security Act. This information is to be used solely for the purpose of receiving such Federal reimbursement funds, and in no way is to be used to discriminate against the persons or t he quality of health care to which they are entitled. All information obtained p ursuant to this Section shall be confidential. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 6 SOURCE: GC § 9990.5. § 9303. Same: Laboratory Services. Laboratory services provided under the provisions o f this Chapter are to be provided only in the laboratories which are appr oved by the Commission or the agency it so designates, in conformance

es. Laboratory services provided under the provisions o f this Chapter are to be provided only in the laboratories which are appr oved by the Commission or the agency it so designates, in conformance with law. SOURCE: GC § 9990.6. § 9304. Same: Certification. Health maintenance organizations shall be certifie d by the Commission, and shall at least meet the conditions of participa tion under Federal law. SOURCE: GC § 9990.7. § 9305. Same: Availability of Services. Health maintenance organizations shall make those services readily available at reasonable times to all enrollees. SOURCE: GC § 9990.8. § 9306. Same: Liability for Fees. Health maintenance organizations shall be liable f or payment at the prevailing and customary fees for reasonable servic es as recognized by the Commission, and in conformity with law, for all out -of-area emergency services as defined in Subdivision (n) of § 9102 re ndered by another provider which are required under the scope of bene fits pursuant to this Chapter. Payment pursuant to this Section shall cov er such emergency treatment as may be reasonable and necessary until the enrollee can be trans- ferred to the provider group in which he is enrolle

Chapter. Payment pursuant to this Section shall cov er such emergency treatment as may be reasonable and necessary until the enrollee can be trans- ferred to the provider group in which he is enrolle d. The provider group in which the patient is enrolled must be notified with in twenty-four (24) hours of the initiation of emergency treatment or hospita lization if on Guam and within seventy-two (72) hours if off-island. SOURCE: GC § 9990.9. § 9307. Same: Employment of Health Professionals. Health maintenance organizations shall employ those health profession- als who are qualified and licensed under the law to perform specific acts of medical care for which they are qualified and licen sed. Health maintenance organizations shall require continuing education fo r all professional personnel engaged in the delivery of health care se rvice. Such continuing COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 7 education shall be that which is recommended by the particular professional organization of which the professional is a member. SOURCE: GC § 9990.10. § 9308. Same: Ratio of Physicians and Health Profes sionals.

hall be that which is recommended by the particular professional organization of which the professional is a member. SOURCE: GC § 9990.10. § 9308. Same: Ratio of Physicians and Health Profes sionals. The ratio of physicians and other allied health pr ofessionals to enrollees in health maintenance organizations shall be set pu rsuant to regulations adopted by the Commission, subject to adjustment as deemed appropriate by the Commission. SOURCE: GC § 9990.11. § 9309. Same: Standards of Care. Health maintenance organizations shall furnish ser vices in such a manner as to provide available and continuous care, quality care and provision of services shall include ready referral of patients to such services at such times as may be medically appropriate. Such supervision and coordination shall be done in such a manner as to p rovide coordinated family care for enrolled families. SOURCE: GC § 9990.12. § 9310. Same: Open Enrollment. Health maintenance organizations shall hold periods of open enrollment when consumers who so desire may enroll, unless a h ealth maintenance organization can demonstrate to the satisfaction of the Commission that it is operating at maximum enrollment capacity.

nrollment when consumers who so desire may enroll, unless a h ealth maintenance organization can demonstrate to the satisfaction of the Commission that it is operating at maximum enrollment capacity. SOURCE: GC § 9990.13. § 9311. Same: Booklet. Health maintenance organizations shall provide a p rinted booklet that is available to all consumers who demonstrate an inter est. The booklet shall contain a description of the available facilities, the days and hours that medical services are available, public and emergenc y transportation, a listing of all health professionals employed or performing services on behalf of the organization, and any such additional information n ecessary to assist the consumer in making a rational, reasonable choice of providers. SOURCE: GC § 9990.14. § 9312. Same: Enrollee Grievance Procedure. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 8 Health maintenance organizations shall establish a n enrollee grievance procedure which shall be in conformity with such pr ocedures as defined and authorized by the Commission. SOURCE: GC § 9990.15. § 9313. Same: Peer Review.

tions shall establish a n enrollee grievance procedure which shall be in conformity with such pr ocedures as defined and authorized by the Commission. SOURCE: GC § 9990.15. § 9313. Same: Peer Review. Health maintenance organizations shall be subject to formalized peer review as established by the Commission. SOURCE: GC § 9990.16. § 9314. Same: Grounds for Disenrollment. Health maintenance organizations shall not disenrol l any enrollee against his wishes without cause as determined by t he Commission, either through public hearings or by regulation. All eligi ble persons who become enrollees, shall remain enrolled in the health main tenance organization of their choice for a benefit period of one (1) year, with the following exceptions: (a) An enrollee who changes his residence; or (b) The health maintenance organization is terminat ed; or (c) The enrollee declares his intent to disenroll t hrough the grievance procedure established by the Commission; or (d) The enrollee declares his intent to voluntarily change HMO's at a time other than the end of the benefit period, he s hall pay a premium; and (e) An enrollee if he is unwilling or unable to fol low the advice of his physician.

ntent to voluntarily change HMO's at a time other than the end of the benefit period, he s hall pay a premium; and (e) An enrollee if he is unwilling or unable to fol low the advice of his physician. SOURCE: GC § 9990.17. § 9315. Same: Enrollee Advisory Board. Health maintenance organizations, to the extent fe asible, shall organize an Advisory Board of Enrollees for the purpose of a dvising the health maintenance organization on matters of primary inte rest to the consumer. SOURCE: GC § 9990.18. § 9316. Same: Emergency Services . Health maintenance organizations shall provide all care including emergency medical services to their enrollees eithe r directly or by COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 9 contracting for such services in such locations as are readily available to the enrollees. Such emergency services shall include, b ut not be limited to: (a) Hospital intensive and coronary care in the hos pital; (b) A team consisting of physicians, nurses and oth er allied health professionals on duty as necessary to provide 24-ho ur service; (c) Equipment, facilities for electrocardiogram, tr ansfusion, inhalation therapy, X-ray and laboratory;

urses and oth er allied health professionals on duty as necessary to provide 24-ho ur service; (c) Equipment, facilities for electrocardiogram, tr ansfusion, inhalation therapy, X-ray and laboratory; (d) Adequate doctor personnel and an enrollment not to exceed one thousand five hundred (1,500) enrollees per full-ti me doctor; (e) Ambulatory care facilities of not less than one thousand (1000) square feet per one hundred (100) enrollees. SOURCE: GC § 9990.19. ---------- ARTICLE 4 BENEFITS § 9401. Benefits: Personal Health Services. § 9402. Same: Mandatory Benefits and Optional Servi ces. § 9401. Benefits: Personal Health Services. (a) The full range of personal health services is covered to include prevention, screening, annual health assessment, di agnosis and treatment of illness, both in and out of hospitals, extended car e, medical rehabilitation, medically justified nursing home care and care prov ided in an organized home care program. (b) A nominal charge for prescription drugs for t he treatment of all illnesses. (c) No payments shall be made for custodial or re sidential care.

nd care prov ided in an organized home care program. (b) A nominal charge for prescription drugs for t he treatment of all illnesses. (c) No payments shall be made for custodial or re sidential care. Payments may be made for medical and nursing servic es performed in custodial or residential living arrangements. (d) Enrollees of any health maintenance organizat ion may seek medical services outside their health maintenance organizat ion, or services in addition to the scope of benefits set forth in this Chapter; provided, however, that such enrollees shall be strictly and solely li able for any such services requested and received. Such enrollee liability sha ll include but is not limited COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 10 to those benefits specifically excluded in this Cha pter pursuant to Article 4, and such extra medical care is not reimbursable und er approved prepaid plans. (e) All charges resulting from an emergency while an enrollee is off- island shall be reimbursable to the enrollee or the ir closest living heir. (f) The Commission shall establish the benefits and limits of liability to be provided by this personal health service

off- island shall be reimbursable to the enrollee or the ir closest living heir. (f) The Commission shall establish the benefits and limits of liability to be provided by this personal health service program . SOURCE: GC § 9990.20. § 9402. Same: Mandatory Benefits and Optional Servi ces. (a) Mandatory benefits under this Chapter applying to Prepaid Health Plans, shall include: (1) Out-patient services which are covered as follo ws: physicians; hospital out-patient; optometric; acupuncture; podi atric; physical therapy; and audiology, insofar as these can be enc ompassed by Federal participation under an approved plan; (2) Hospital in-patient care; (3) Nursing home care (when available in Guam), inc luding physician services and prescription drugs; (4) Purchase of prescription drugs prescribed by a physician for the treatment of all medical conditions at a nomina l charge; (5) Hospital out-patient dialysis services and home hemodialysis services, including physician services, medical sup plies, drugs and equipment required for dialysis; (6) Out-patient laboratory and out-patient x-ray se rvices; (7) Blood and blood derivatives; (8) Dental services; (9) Preventive services (physical

p plies, drugs and equipment required for dialysis; (6) Out-patient laboratory and out-patient x-ray se rvices; (7) Blood and blood derivatives; (8) Dental services; (9) Preventive services (physical examinations, wel l baby care, immunizations and injections); (10) Basic dental services (examination, prophylaxi s, x-rays, routine fillings and extractions, emergency treatme nt); (11) Emergency care on and off-island (including am bulance); (12) Durable medical equipment and medical supplies ; COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 11 (13) Other diagnostic screening or preventive servi ces. (b) Optional Services shall include: (1) Eyeglasses; (2) Comprehensive dental care (dentures, crown and bridgework, root canal, etc.); (3) Home health care; (4) Prosthetic devices and hearing aids; (5) Out-patient services including chiropractic, ps ychology, occupational therapy, speech therapy. (c) For providers who are not Prepaid Health Plans, the benefits of Subdivision (a)(6) shall apply, but such benefits s hall be subject to the following limitations: (1) Nursing home care shall be limited to one hundr ed twenty (120) days per benefit period; (2)

s of Subdivision (a)(6) shall apply, but such benefits s hall be subject to the following limitations: (1) Nursing home care shall be limited to one hundr ed twenty (120) days per benefit period; (2) Prescription drugs shall be excluded, except th ose required for long-term treatment of chronic disease; (3) Cosmetic surgery shall be excluded unless appro ved by psychiatric consultation or vocational rehabilitati on agency and related employment. (d) Services to be provided by the government of Guam through the Department of Public Health and Social Services, sh all include: (1) Speech, occupational and audiology therapy; (2) Rehabilitative services; (3) Psychiatric care; and (4) Long-term treatment of infectious disease. SOURCE: GC § 9990.21. ---------- ARTICLE 5 CONSUMER HEALTH PROTECTION PREMIUM § 9501. Consumer Health Protection Premium: Definit ions. § 9502. Same: Employee Premium. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 12 § 9503. Same: Employer Premium. § 9504. Same: Individual Premium. § 9505. Same: Federal Legislation. § 9506. Amendments. § 9501. Consumer Health Protection Premium: Definit ions.

TH PROTECTION ACT 12 § 9503. Same: Employer Premium. § 9504. Same: Individual Premium. § 9505. Same: Federal Legislation. § 9506. Amendments. § 9501. Consumer Health Protection Premium: Definit ions. (1) Employer means any individual or body of person s, corporate or unincorporated, public or private, the government o f Guam or subject to the laws of Guam, making payment of wages to employees for services performed within Guam or the person having control of the payment of such wages, whether or not the person having control of the payment of such wages is subject to the jurisdiction of the laws of Guam. (2) Wages means all remuneration (other than fees paid to a public official) for services performed by an employee for his employer, including all remuneration paid to a nonresident employee for services, performed in Guam and, the cash value of all remuneration paid i n any medium other than cash; except that such term shall not include remun eration paid for services, the total value of which does not exceed Fifty Doll ars ($50) per week, or for active services as a member of the Armed Forces of the United States; or for agricultural labor (as defined in '3131(g) of the Internal

of which does not exceed Fifty Doll ars ($50) per week, or for active services as a member of the Armed Forces of the United States; or for agricultural labor (as defined in '3131(g) of the Internal Revenue Code of 1954); or for domestic service in a private home; f or services performed by a duly ordained, commissioned or licensed minister of the church in the exercise of his ministry or by a member of a religi ous order in the exercise of duties required by such order; or for services perf ormed by an individual under the age of eighteen (18) in the delivery or s ale of newspaper; or in the form of group-term life insurance on the life of an employee. (3) Employee means a resident of the territory of Guam. (4) Payroll Period means a period for which a pay ment of wages is ordinarily made to the employee by his employer. (5) Business Income in the case of an individual, means gross income minus the deductions authorized as business expense s on Form 1040 Internal Revenue Service, minus rental income; dividend inco me gains or losses from the sale or exchange of an individual's capital ass ets; royalties; alimony and separate maintenance payments; income from an inter est in an

inus rental income; dividend inco me gains or losses from the sale or exchange of an individual's capital ass ets; royalties; alimony and separate maintenance payments; income from an inter est in an estate or trust; and income from annuities, life insurance and endow ment contract and pensions. SOURCE: GC § 9990.22. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 13 § 9502. Same: Employee Premium. There shall be imposed for each taxable year upon the wages paid every employee, subject to the Consumers Health Protectio n Act a fixed consumers health protection premium, based on one-h alf of reasonable cost of care as determined by the Commission for the emp loyee, and a fixed premium based on the reasonable cost care for his d ependents who are not otherwise covered by a health protection plan. SOURCE: GC § 9990.23. § 9503. Same: Employer Premium. There shall be imposed for each taxable year upon t he wages paid by every employer to employees, subject to the Consume rs Health Protection Act a fixed consumer health protection premium, bas ed on one-half of the reasonable cost of care as determined by the Commis sion for each employee. SOURCE: GC § 9990.24.

onsume rs Health Protection Act a fixed consumer health protection premium, bas ed on one-half of the reasonable cost of care as determined by the Commis sion for each employee. SOURCE: GC § 9990.24. § 9504. Same: Individual Premium. There shall be imposed for each taxable year upon t he business income of every individual, subject to the Consumer Health Protection Act, from which the consumer health protection premium is not deducted and withheld, a fixed consumer health protection premiu m based on the reason- able cost of care, to be determined by the Commissi on. Individuals not employed or covered under Medicai d or Medicare, shall pay twenty-five per cent (25%) of a fixed consumer health protection premium based on the reasonable cost of care to be determined by the Commission. The government of Guam will pay the bal ance of seventy-five per cent (75%) of such fixed premium from appropria tions for such purpose. SOURCE: GC § 9990.25. § 9505. Same: Federal Legislation. The provisions of this Chapter shall continue to be operative, and shall be merged or rearranged in accordance with any Fede ral legislation that provides similar or equivalent benefits, if and whe n such

rovisions of this Chapter shall continue to be operative, and shall be merged or rearranged in accordance with any Fede ral legislation that provides similar or equivalent benefits, if and whe n such Federal legislation is enacted. Fiscal arrangements pursuant to such en acted Federal law shall be accomplished by the Commission in accordance with l aw. SOURCE: GC § 9990.26. § 9506. Amendments. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 14 No provision of this Chapter and no amendment to th e Government Code made by this Chapter, shall affect or alter an y contractual or other nonstatutory obligation of an employer to provide h ealth services to his present and former employees and their dependents o r to any such persons, or the amount of any obligation for payment (includ ing any amount payable by an employer for insurance premiums or into a fun d to provide for any such payment) toward all or any part of the cost of such services. And, such employer-employee negotiated funds as currently exi st may be used to meet the obligation of premiums on behalf of the employe e. SOURCE: GC § 9990.27.

ny part of the cost of such services. And, such employer-employee negotiated funds as currently exi st may be used to meet the obligation of premiums on behalf of the employe e. SOURCE: GC § 9990.27. ---------- ARTICLE 6 MATERNAL AND CHILD HEALTH AND CRIPPLED CHILDREN NOTE: Article 6 was repealed by P.L. 22-130:1; however, t he same subject matter is found in Article 4 of Chapter 3 of this Title. ---------- ARTICLE 7 MATERNAL AND CHILD HEALTH SERVICES NOTE: Article 7 was repealed by P.L. 22-130:1; however th e same subject matter is found in Article 5 of Chapter 3 of this Title. ---------- ARTICLE 8 SERVICES FOR CRIPPLED CHILDREN NOTE: Article 8 was repealed by P.L. 22-130:1; however th e same subject matter is found in Article 6 of Chapter 3 of this Title. ---------- ARTICLE 9 HEALTH CARE PROMPT PAYMENT ACT OF 2000 § 9901. Definitions § 9902. Prompt Payment for Health Care and Health I nsurance Benefits § 9903. Timely Filing of Accurate Claims § 9904. Billing of Patients Allowed COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 15 § 9905. Damages. § 9906. Cumulative Remedies. § 9907. Effective Dates. § 9908. Existing Contracts to Prevail.

ents Allowed COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 15 § 9905. Damages. § 9906. Cumulative Remedies. § 9907. Effective Dates. § 9908. Existing Contracts to Prevail. NOTE: This Article was enacted in its entirety by P.L. 25 -189:3. Compiler has renamed this Article the AHealth Care. . . Act @ to differentiate it from the other Prompt Payment Act in Title 5 GCA, which deals with paymen ts by the Government of Guam. § 9901. Definitions . For the purpose of this Chapter, the following wor ds and phrases have the meanings assigned to them, respectively, except where the context otherwise requires: (a) >Claim = means any claim, bill, or request for payment for all or any portion of healthcare services provided by a health care provider, or services submitted by an individual pursuant to a contract o r agreement with a payer entity.a patient or Health Care Provider that is el igible for reimbursement. (b) >Clean Claim = means a claim, or portion thereof, that may be processed without a reasonable request for addition al information from the provider of service or from a third party, but does not include any claim under investigation for fraud or abuse

hat may be processed without a reasonable request for addition al information from the provider of service or from a third party, but does not include any claim under investigation for fraud or abuse or claims un der review for medical necessity. In no event may a claim be contested or denied for the lack of information that has no factual impact upon the Hea lth Plan Administrator =s ability to adjudicate the claim. (c) >Contest ,= >contesting = or >contested = means the circumstances under which a payer entity was not provided with, or did not have reasonable access to, sufficient pertinent information needed to determine payment liability or basis for payment of the claims. (d) >Deny, = >denying = or >denied = means the assertion by a Health Plan Administrator that it has no, or partial, liability to pay a claim based upon eligibility of the patient, coverage of a service, medical necessity of a service, liability of another payer or other ground s. (e) >Health Plan Administrator = means insurance companies, health plan providers, all companies defined as third part y payers, including, but not limited to, health maintenance organizations, m edical service organizations,

ator = means insurance companies, health plan providers, all companies defined as third part y payers, including, but not limited to, health maintenance organizations, m edical service organizations, governmental organizations, worker =s compensation organization, or other legal entities providing or applying to provide third COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 16 party payment or health insurance or payment for he althcare services that are organized and operating under the laws of Guam. (f) >Health Care Provider = means any health care facility, hospital, clinic, laboratory, nursing home, home health agenc y, pharmacy, physician, dentist, nurse, acupuncturist, chiropractor, or any other practitioner or organized entity certified or licensed to provide h ealth care services on Guam. § 9902. Prompt Payment for Health Care and Health I nsurance Benefits . (a) This Section applies to Health Plan Administra tors, as defined by this Chapter, organized and operating under the law s of Guam. (b) Health Plan Administrators shall reimburse a Cl ean Claim, or any portion thereof, submitted by a patient or Health C are Provider, that is eligible for

zed and operating under the law s of Guam. (b) Health Plan Administrators shall reimburse a Cl ean Claim, or any portion thereof, submitted by a patient or Health C are Provider, that is eligible for payment and not contested or denied no t more than 45 calendar days after receiving the Clean Claim filed in writi ng. (c) If a claim is contested or denied, or requires more time for review by the Health Plan Administrator, the Health Plan Admi nistrator shall notify the Health Care Provider in writing not more than thirt y (30) calendar days after receiving a claim filed for payment. The notice sh all identify the contested or denied portion of the claim and the specific rea son for contesting or denying the claim, and may request additional infor mation. Requests for information on a contested or denied claim, or port ion thereof, shall be reasonable and relevant to the determination of why the claim is being contested or denied. In no event may a claim be co ntested or denied for the lack of information that has no factual impact upon the Health Plan Administrator =s ability to adjudicate the claim.

eing contested or denied. In no event may a claim be co ntested or denied for the lack of information that has no factual impact upon the Health Plan Administrator =s ability to adjudicate the claim. (d) If information received pursuant to a request f or additional information is satisfactory to warrant paying the C lean Claim, the Clean Claim shall be paid not more than 45 calendar days after receiving the additional information in writing. (e) The payment of a Clean Claim under this Section shall be effective upon the date of postmark of the mailing. (f) Health Care Providers shall be responsible for obtaining proof in writing that a specific claim was delivered to a He alth Plan Administrator on a specific date for determining the time periods fo r the purposes of prompt payment. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 17 (g) Notwithstanding any provisions to the contrary, interest shall be allowed to accrue at a rate of 12% per annum as dam ages for money owed by a Health Plan Administrator for payment of a Cle an Claim, or portion thereof, that exceeds the applicable reimbursement time limitations under this Section, including applicable

es for money owed by a Health Plan Administrator for payment of a Cle an Claim, or portion thereof, that exceeds the applicable reimbursement time limitations under this Section, including applicable costs for collec ting past due payments as provided in § 9905 of this Article, as follows: (1) for an uncontested Clean Claim: (i) filed in writing, interest from the first cal endar day after the 45-day period in § 9902(b); or (2) for a contested claim, or portion thereof, file d in writing: (i) for which notice was provided under § 9902(c) , interest from the first calendar day forty-five (45) days af ter the date the additional information is received; or (ii) for which notice was not provided, but not w ithin the time specified under § 9902(c), interest from the first calendar day after the claim is received. (h) Each Health Care Provider shall notify the Heal th Plan Administrator and patient in writing of all claims for which they intend to charge interest. Any interest that accrues as a re sult of the delayed payment of a Clean Claim, or any portion thereof, in accord ance with the provisions of this Act shall be automatically added by the Hea lth Plan Administrator to the

rues as a re sult of the delayed payment of a Clean Claim, or any portion thereof, in accord ance with the provisions of this Act shall be automatically added by the Hea lth Plan Administrator to the amount of the unpaid Clean Claims due the Healt h Care Provider. (i) Interest shall only apply to the principal por tion of the claim. (j) The provisions of this Section shall not apply to the payment or reimbursement of any claim, or portion thereof, inv olving a Coordination of Benefits between multiple payers of a claim. § 9903. Timely Filing of Accurate Claims . (a) This Section applies to Health Care Providers, as defined by this Act, duly certified, licensed, or organized and ope rating under the laws of Guam. (b) All claims submitted for reimbursement must be submitted on a UB- 92, HCFA 1500, ADA claim, or other billing document generally accepted by Health Plan Administrators. Claims may be submi tted electronically if COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 18 such a transmittal arrangement has been agreed to b y the Health Plan Administrator. (c) Health Care Providers shall be responsible for the accuracy of all claims filed.

UMER HEALTH PROTECTION ACT 18 such a transmittal arrangement has been agreed to b y the Health Plan Administrator. (c) Health Care Providers shall be responsible for the accuracy of all claims filed. Duplicate claims, unbundled claims, or fee-for-service claims billed in a capitated arrangement, may not be submi tted and cannot be considered for prompt payment in accordance with th e provisions of this Act. (d) Should a Health Care Provider fail to submit a response to a reasonable request for additional information on a contested or disputed claim, within 45 days from the date of request for such additional information, no interest shall accrue to the claim or portion thereof eligible for payment. For purposes of this Subsection, shou ld a Health Care Provider be a hospital, then such a hospital provider shall be allowed to submit a response to a reasonable request for additional inf ormation on a contested or disputed claim within 90 days from the date of requ est for such additional information. (e) In order for a Health Care Provider to receive interest for the late payment of a claim as provided in § 9902, a claim f or health services rendered must be submitted within 45 days

information. (e) In order for a Health Care Provider to receive interest for the late payment of a claim as provided in § 9902, a claim f or health services rendered must be submitted within 45 days from the date the health service was provided. (f) With the exception of those claims that involve the coordination of benefits, all claims for payment must be submitted by the Health Care Provider within 90 days from the date that health s ervices were rendered. Any claim not submitted by the Health Care Provider within 90 days from the date that health services were rendered shall n ot be the financial responsibility of either the Health Plan Administra tor or the patient. § 9904. Billing of Patients Allowed . (a) No patient receiving care from a Health Care P rovider, may be billed for the same Clean claim, or portion thereof , submitted for payment to a Health Plan Administrator, unless the provider ha s elected to terminate that person =s efforts to collect interest penalties as provided for in § 9902(g) of this Act, or a period of 90 days has lapsed from th e date of submission of a Clean Claim for payment.

o terminate that person =s efforts to collect interest penalties as provided for in § 9902(g) of this Act, or a period of 90 days has lapsed from th e date of submission of a Clean Claim for payment. This provision shall not apply to any Clean Claim or portion of a Clean Claim that is due and payable by the patient as a benefit limitation, deductible, co-payment, non-cov ered benefit, patient share, or personal comfort or convenience item. COL5/21/202110 GCA HEALTH AND SAFETY CH. 9 CONSUMER HEALTH PROTECTION ACT 19 (b) A Health Care Provider may not charge more than (12%) interest per annum to any patient as a penalty for their fai lure to make prompt payment of a Clean Claim, or portion thereof, for w hich the patient is responsible for paying. (c) A Health Care Provider may not charge both the Health Plan Administrator and the patient interest penalties fo r the same Clean Claim, or portion thereof, submitted for payment to either pa rty. § 9905. Damages. In any action or proceeding for violation of the r equirements of this Act, the Health Plan Administrator or the Health Care Pr ovider shall be entitled to recover all costs of litigation or arbitration,i ncluding reasonable

ng for violation of the r equirements of this Act, the Health Plan Administrator or the Health Care Pr ovider shall be entitled to recover all costs of litigation or arbitration,i ncluding reasonable attorneys = fees or arbitration costs, incurred in the successf ul prosecution of the action or proceeding. § 9906. Cumulative Remedies. The provisions of this Act are not exclusive. The remedies provided herein are in addition to any other remedy or proce dure provided by any other law or at common law. § 9907. Effective Dates. The provisions of this Article shall not apply to any claim filed prior to the date of enactment. The Article shall take effec t 60 days from the date of enactment into law, with the exception of the Gover nment of Guam =s Medically Indigent Program ( MIP ) whose effective date for implementation of the provisions of this Article shall be March 1, 2001. NOTE: This Article was enacted on January 18, 2001, so th e effective date for all but the MIP Program is March 19, 2001. The Compiler has changed the word AAct @ to AArticle @ to conform with the codification of P.L. 25-189 in this Article. § 9908. Existing Contracts to Prevail.

l but the MIP Program is March 19, 2001. The Compiler has changed the word AAct @ to AArticle @ to conform with the codification of P.L. 25-189 in this Article. § 9908. Existing Contracts to Prevail. The provisions of this Article shall not supercede any contract in force between a Health Plan Administrator and a Health Ca re Provider as of the effective date of the Act. ---------- COL5/21/2021 COL5/21/2021