Guam § 9102 - Definitions.

§ 9102. Definitions.

(a) “Prepaid Health Plan” means a plan which offers a specified scope of benefits to an enrolled

population for a predetermined prepaid annual rate.

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(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 given population

of enrolled consumers in a Prepaid Health Plan. Providers shall guarantee that quality services be available

and accessible twenty-four (24) hours a day, seven (7) days a week. The definition of health maintenance

organization under this Subdivision shall include, but not be limited to, medical care foundations, group

practice prepayment organizations and health consumer organizations.

(1) “Medical care foundation” means any non-profit foundation whose physician membership is

capable and guarantees to provide comprehensive health services to patients enrolled in a Prepaid

Health Plan.

(2) “Health consumer organization” means any incorporated organization of citizens whose

primary motive for organizing is to create a system of financing and arranging for the delivery of

personal health services under circumstances which require sensitivity to the consumer’s desires in

this field.

(3) A “group practice prepayment organization” means a formal, organized group of doctors and

other providers in a group practice center with centralized management peer review, and a formal

structure and organization.

(c) “Fiscal Intermediary” means any private insurance company which performs fiscal and

administrative functions for any 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 medical

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 hospitals, and unwarranted length of stays in hospitals.

(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 engaged in the providing of personal

health service to the public.

(h) “Health Commission” means that body under which this legislation assumes powers and

responsibility for activities related 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 other 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 health benefits.

(l) “Benefit Period” means the period of time during which an enrolled person is covered under a

Prepaid Health Plan.

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(m) “Allied Health Professional” means any professional person involved in the provision of skilled

health service both directly or indirectly in support of physicians and health institutions engaged in the

delivery of health care services.

(n) “Out of Area Emergency Services” means medical treatment for any sudden or unexpected illness,

or the medical treatment 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 quality of care

or safety of the patient by delaying treatment. This shall include any emergency services provided to an

enrollee while off-island.

(o) “Enrollee” means a person who has enrolled as a beneficiary of a health benefit plan.