Guam § 6103 - Plan.

§ 6103. Plan.

Prepaid Health Plans contracting under this Chapter shall guarantee

and provide assurances to the Department 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 Plans own facilities or through arrangements with another

provider which has been approved by the Department. The Department is

hereby directed to establish standards of care and to conduct testing and

review procedures to assure compliance with such standards.

It is in the public interest that medical assistance 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

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objective 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 determination 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 medicaid

health services as set forth in Federal requirements 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 contracts

thereunder, the Department shall give due consideration to the reputation of

the prepaid health organization in providing such benefits, to the

accessibility and availability of its facilities and resources for health care to

enrolled persons under this Chapter, 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 facilities meet quality program standards.

These standards shall require the Prepaid Health Plan to demonstrate to the

Department that it has adequate financial resources, physical facilities,

organizational and administrative capacities, and a sound program 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. Certified 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 Department.

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 for such services shall cover treatment of

emergency conditions provided plan has been notified within seventy- two

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(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 procedures 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

Department.

If the enrollee has an unresolved grievance, a fair hearing shall be

made available under appropriate provisions of the Government Code of

Guam to resolve all grievances regarding care and administration of the

plan. Findings and recommendations of the Director based on the results of

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 satisfaction and

dissatisfaction, quality and utilization.