(a) ‘Administrator’ means the administrator of the
Guam Medically Indigent Program.

(b) ‘Clean Claim’ means a claim, that may be processed without the need of additional 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 under 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 Health Plan Administrator’s ability to adjudicate the claim.

(c) ‘Department’ means the Department of Public
Health and Social Services.

(d) ‘Director’ means the Director of the Department of
Public Health and Social Services.

(e) ‘Eligible Person’ means any person who is:

(1) a resident of Guam and has been a resident of
Guam for a period of no less than six (6) months; and

(A) who has been physically living on Guam within the last six (6) months of the year, except for temporary absences in the past year which cannot be reasonably construed as absences due to bona fide residency outside of Guam;

(B) who applies for and qualifies for assistance under this Article;

(C) who is unable to pay the cost of the necessary medical care; and who also:

(2) is not eligible for Medicaid or Medicare coverage and has exhausted all benefits under Title XVIII or XIX of the Social Security Act; or the State

COL 8/23/2023

10 Guam Code Ann. HEALTH AND SAFETY
CH 2 DIVISION OF PUBLIC WELFARE

Children’s Health Insurance Program under Title XXI
of the Balanced Budget Act as of 1997; or

(A) does not have medical insurance coverage nor the financial ability to pay for medical insurance coverage or for medical services as determined by the cost-sharing Program developed by the Administrator based upon the criteria established in this Article; or

(B) who has medical insurance coverage, but such coverage is inadequate to cover the cost of medically required treatment and is otherwise qualified for the Program as a result of inadequate income or other resources;

(3) is a child in foster care, age eighteen (18) years and below, for whom public agencies are assuming financial responsibility in whole or in part; or

(4) is eligible for temporary emergency medical or other special care as provided in § 2905.3.

(f) ‘Federal Poverty Guideline’ means the poverty guidelines updated annually in the Federal Register by the U.S. Department of Health and Human Services under authority of §673(2) of the Omnibus Budget Reconciliation Act of 1981.

(g) ‘Guam MIP Income Guidelines’ means the Federal poverty guidelines adjusted for the higher cost of living on Guam relative to the national standard.

(h) ‘Medical Necessity’ or ‘Medically Necessary’ must be determined on an individual basis and must consider available research findings, health care practice guidelines and standards issued by professionals, recognized organizations or government agencies. ‘Medical Necessity’ or ‘Medically Necessary’ means the treatment must be certain to save lives or significantly alter an adverse prognosis:

(1) in accordance with generally accepted standards of medical practice; and

COL 8/23/2023

10 Guam Code Ann. HEALTH AND SAFETY
CH 2 DIVISION OF PUBLIC WELFARE

(2) clinically appropriate in terms of type, frequency, extent, site and duration.

(i) ‘Member’ means an eligible person who enrolls in the Program.

(j) ‘Non-Provider’ means a person who provides hospital, medical, dental or behavioral health care, but does not have a contract or subcontract with the Program.

(k) ‘Practitioner’ means a person licensed pursuant to Chapter 12 of Division 1, Part 1 of Title 10 of the Guam Code Annotated.

(l) ‘Prepaid capitated’ means a mode of payment by which a health care Provider directly delivers health care services for the duration of a contract to a maximum specified number of members based on a fixed rate per member notwithstanding:

(1) the actual number of members who receive care from the Provider; or

(2) the amount of health care services provided to any member.

(m) ‘Primary Care Physician’ means a physician who is a family practitioner, general practitioner, pediatrician, general internist, obstetrician, psychiatrist or gynecologist.

(n) ‘Primary Care Practitioner’ means a nurse practitioner licensed pursuant to Article 3 of Chapter 12, Division 1, Part 1 of Title 10 of the Guam Code Annotated, or a physician’s assistant licensed pursuant to Article 16 of Chapter 12, Division 1, Part 1 of Title 10 of the Guam Code Annotated. Nothing in this Act shall expand the scope of practice for nurse practitioners or for physician assistants as defined in Chapter 12 of Division 1, Part 1 of Title 10 of the Guam Code Annotated.

(o) ‘Provider’ means any person who contracts with the Program for the provision of hospitalization, medical, dental or behavioral health care to members according to the

COL 8/23/2023

10 Guam Code Ann. HEALTH AND SAFETY
CH 2 DIVISION OF PUBLIC WELFARE

provisions of this Chapter, or any subcontractor of such
Provider delivering services pursuant to this Article.

(p) ‘Program’ means the Guam Medically Indigent
Program established by this Article.

2017 NOTE: Subsection/subitem designations added/altered pursuant to the authority of 1 Guam Code Ann. § 1606.

This section was originally added by P.L. 17-083:3 (Dec. 21, 1984), entitled “”Medically Indigent Persons; Defined.”” Repealed by P.L. 25-
163:2 (Sept. 30, 2003).

2012 NOTE: In maintaining the general codification scheme of the GCA the Compiler changed the hierarchy of subsections beginning with “”Lowercase Roman Numerals”” to “”Uppercase Letters”” in subsection (e)(1).