(a) There is established within the Department of Public Health and Social Services, within the Division of Public Welfare, a Program unit entitled the ‘Bureau of Health Care Financing Administration,’ which shall administer the Guam Medicaid Program and the Guam Medically Indigent Program, subject to the requirements and exceptions of this Article.

(b) The Administrator has full operational responsibility for the Program, subject to supervision by the Chief Human Services Administrator of the Division of Public Welfare with such duties that may include any or all of the following:

(1) Defining eligibility for financial assistance with health care costs, consistent with § 2905 of this Article;

(2) Development of implementation and operation plans for the Program, which include reasonable access to hospitalization, medical, dental and behavioral health care services for members, as provided by this Article.

(3) Contract administration, certification and oversight of Providers.

(4) Provision of technical assistance services to
Providers and potential Providers.

COL 8/23/2023

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

(5) Development of a complete system of accounts and controls for the Program, including provisions designed to ensure that covered health services provided through the Program are not used unnecessarily or unreasonably, including, but not limited to, inpatient mental health services provided in a hospital. The Administrator shall regularly compare the scope, utilization rates, utilization control methods and unit prices of major health care services provided on Guam in comparison with Program health care services to identify any unnecessary or unreasonable utilization within the Program. The Administrator shall periodically assess the cost effectiveness and health implications of alternate approaches to the provision of covered health and medical services through the Program in order to reduce unnecessary or unreasonable utilization.

(6) Establishment of peer review and utilization review functions for all Providers.

(7) Assistance in the formation of medical, dental and behavioral health care consortiums to provide covered health and medical services under the Program.

(8) Development and management of a Provider payment system.

(9) Establishment and management of a comprehensive system for assuring the quality of care delivered by the Program.

(10) Establishment and management of a system to prevent fraud by members, eligible persons and Providers of the Program.

(11) Development of a health education and information program.

(12) Development and management of a participant enrollment system.

(13) Establishment of a system to implement medical child support requirements, as required by Federal and local law. The Administrator may enter into an intergovernmental

40

COL 8/23/2023

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

agreement with the Department of Law to implement the provisions of this Subsection.

(14) Except for reinsurance obtained by Providers, the Administrator shall coordinate benefits provided under this Article to an eligible person who also is covered by workers’ compensation, disability insurance, a health care services organization, an accountable health plan, or any other health or medical or disability insurance plan, including coverage made available to eligible persons or who receives payments for accident-related injuries, so that any costs for hospitalization, medical, dental or behavioral health care paid by the Program are recovered from any other available third- party payers.

(A) The Administrator may require that Providers and Non-Providers are responsible for the coordination of benefits for services provided under this Article.

(B) Requirements for coordination of benefits by Non-Providers under this Section shall be limited to coordination with standard health insurance and disability insurance policies, and similar programs for health coverage.

(C) The Program shall act as a payer of last resort for eligible persons as defined by this Article, unless specifically prohibited by Federal or local law.

(D) The Administrator may require eligible persons to assign to the system rights to all types of medical benefits, to which the person is entitled, including, but not limited to, first-party medical benefits under automobile insurance policies.

(E) The government of Guam has a right to subrogation against any other person or firm to enforce the assignment of medical benefits.

(F)The provisions of this Subsection are controlling over the provisions of any insurance policy, which provides benefits to an eligible person if the

41

COL 8/23/2023

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

policy is inconsistent with the provisions of this
Subsection.

(15) The Administrator shall require as a condition of a contract with any Provider that all records relating to contract compliance are available for inspection by the Administrator or the Director and that such records be maintained by the Provider for five (5) years. The Administrator shall also require that a Provider make such records available on request of the Secretary of the United States Department of Health and Human Services, or its successor agency.
(16) The Administrator shall establish procedures for: (A) the transition of patients between system
Providers and Non-Providers; and

(B) the referral of members and persons who have been determined eligible to hospitals and other medical facilities, which have contracts to care for such persons.

(17) The Administrator shall set forth procedures and standards for use by the Program in requesting long-term care for members or persons determined eligible.

(18) As a condition of the contract with any Provider, the Administrator shall require such contract terms as are necessary, in the judgment of the Administrator, to ensure adequate performance and compliance with all applicable local and Federal laws by the Provider of th e provisions of each contract executed pursuant to this Article.

(A) Contract provisions required by the Administrator may include, but are not limited to, the maintenance of deposits, performance bonds, financial reserves or other financial security.

(B) The Administrator may waive requirements for the posting of bonds or security for Providers which have posted other security, equal to or greater than that required by the system, with a local agency for the performance of health service contracts if funds would be available from such security for the Program upon default by the Provider.

42

COL 8/23/2023

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

(C) The Administrator may also establish procedures, which provide for the withholding or forfeiture of payments to be made to a Provider by the Program for the failure of the Provider to comply with a provision of the Provider’s contract with the Program or with the provisions of adopted rules.

(19) If the Administrator determines that it is more cost effective for an eligible person to be enrolled in a group health insurance plan in which the person is entitled to be enrolled, the Program may pay all of that person’s premiums, deductibles, coinsurance and other cost sharing obligations for services covered under the Program. The person shall apply for enrollment in the group health insurance plan as a condition of eligibility under § 2903 (e) through § 2905.

(20) If the Administrator determines that it is more cost effective to provide for the medical management of a Program participant’s health care needs with the provision of services that may fall outside the defined Program benefits, such treatment may be pursued; provided, that there will be a significant beneficial outcome to the patient’s health status and the total cost of this alternate treatment regime does not exceed a total cost of Seventy-five Thousand Dollars ($75,000.00). Treatment outside the defined Program benefits, must take place at teaching hospitals or be sanctioned by the Federal, Drug Administration as an experimental drug or procedural practice.

(c) The Director, in consultation with the Administrator, shall promulgate, subject to the Administrative Adjudication Law, a process for the periodic updating and revision of Program Benefits based upon an annual review of Program enrollment, utilization and claims payment and operating expenses.

(d) The Director, in consultation with the Administrator, shall establish Guam MIP Income guidelines and annually review and adjust pursuant to the Administrative Adjudication Law.

(e) Subject to the Administrative Adjudication Law, the Sunshine Reform Act of 1999 and the Health Insurance Portability and Accountability Act (HIPAA) which affects all health

43

COL 8/23/2023

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

insurance entities regarding the type of Protected Health Information (PHI) that they are allowed to disclose and to whom they are to disclose it to, the Director, in consultation with the Administrator, shall prescribe by rules and regulations the types of information that are confidential, and circumstances under which such information may be used or released, including requirements for physician-patient confidentiality. Such rules shall be designed to provide for the exchange of necessary information among Providers, the Administrator and the Department for purposes of eligibility determination or coordination of eligible medical care under this Article.

SOURCE: Added by P.L. 27-030:2 (Sept. 30, 2003).

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

This section was originally added by P.L. 17-083:3 (Dec. 21, 1984),
entitled “”Income.”” Repealed and reenacted by P.L. 25-163:2 (Sept. 30,
2003), entitled “”Establishment of Program Administrator.”” Repealed by
P.L. 27-030:2 (Sept. 30, 2003).