Guam § 4302 - Same: Health Insurance or Provision of Health Care.

§ 4302. Same: Health Insurance or Provision of Health Care.

(a) All companies or other legal entities providing or applying to provide health insurance or the

provision of health care to government of Guam employees and foster children shall make their audited

financial statements available to the Director of Administration annually. Such records shall be public

records.

(b) The Director of Administration shall, no later than March 1, 1986, promulgate rules and regulations

setting forth the other information she/he requires from the companies or legal entities and the method by

which such information shall be reported.

(1) This information shall be equitably required of each company and shall be submitted no less

than ten (10) days before any negotiations or active consideration of proposals commences.

(2) Materials submitted in fulfillment of this requirement shall not be considered public records,

except for the detailed claims utilization and cost information required by § 4302(g), which shall be

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provided to current and prospective health insurance carriers as part of the invitation to bid for

coverage to government of Guam employees and retirees, and foster children.

(c) [No text]

(1) The Government of Guam Health Insurance Negotiating Team shall consist of

(A) the Director of Administration, who shall be the Chairperson;

(B) the Administrator of the Department of Integrated Services for Individuals with

Disabilities (DISID), or his or her designee;

(C) the Director of the Bureau of Budget and Management Research, or his or her designee;

(D) an employee representative from the Judicial Branch to be appointed by the Chief Justice

of the Supreme Court of Guam. Should the Judicial Branch decide to enter into a health insurance

contract separate from the Executive Branch as authorized in 4 GCA § 4301(c), an employee

representative from the Executive Branch shall be appointed by I Maga’hågan/Maga’låhen

Guåhan to replace the employee representative from the Judicial Branch on the Government of

Guam Health Insurance Negotiating Team for the applicable fiscal year;

(E) an employee representative of the Legislative Branch to be appointed by the Speaker of

I Liheslaturan Guåhan. Should the Legislative Branch decide to enter into a health insurance

contract separate from the Executive Branch as authorized in 4 GCA § 4301(c), an employee

representative from the Executive Branch shall be appointed by I Maga’hågan/Maga’låhen

Guåhan to replace the employee representative of the Legislative Branch on the Government of

Guam Health Insurance Negotiating Team for the applicable fiscal year;

(F) the Superintendent of the Department of Education, or his or her designee;

(G) the Director of the Government of Guam Retirement Fund, or his or her designee;

(H) a retiree who is a member of the Government of Guam Retirement Fund to be appointed

by the Board of Trustees of the Government of Guam Retirement Fund;

(I) one (1) member of the general public, appointed by I Maga’hågan/Maga’låhen Guåhan,

who is not an employee of the government of Guam, not an employee of a health insurance

company, hospital, or medical provider, or not an appointee by I Maga’håga/Maga’låhi to any

government agency, board or commission, and who shall affirm by affidavit that he or she agrees

to comply with all provisions in Chapter 15 of Title 4 of the Guam Code Annotated, also known

as the Standard of Conduct for Elected Officers, Appointed Officers, and Public Employees of

the government of Guam;

(J) the Chairperson of the Committee on Health or the successor committee of I Liheslaturan

Guåhan, or his or her designee, who shall sit as an ex-officio non-voting member; and

(K) the Chairperson of the Committee on Appropriations, or the successor committee of I

Liheslaturan Guåhan, or his or her designee, who shall sit as an ex-officio non-voting member.

(2) The Negotiating Team shall examine the financial information of the prepaid health insurance

companies, health care providers or other legal entities for the purpose of developing the most

economical and beneficial health plan for the government of Guam employees and retirees, and foster

children.

(3) The Negotiating Team may obtain technical support from other financial and health-related

agencies.

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(4) The Negotiating Team shall develop its rules of procedure in accordance with the

Administrative Adjudication Law.

(5) The Negotiating Team shall develop minimum qualification for proposals to be submitted for

health insurance coverage.

(6) The Negotiating Team shall also develop a ranking system to rank the proposals.

(7) The Negotiating Team, with the approval of I Maga’håga/Maga’låhi, is authorized to contract

an actuary competent to develop proposed health insurance rates or other recognized expert to train

and/or advise the Negotiating Team.

(8) Notwithstanding any other provision of law, each fiscal year, the Negotiating Team shall

solicit both exclusive and non-exclusive proposals from each Health Insurance Provider and enter into

negotiations with the top three (3) ranked Health Insurance Providers submitting qualified proposals

for health insurance coverage for qualified active employees and qualified retirees, and foster children,

of the government of Guam.

(A) The Director of the Department of Administration shall plan, and implement prior to

discussions for the 2011-2012 Fiscal Year, an expanded competitive Request for Proposal

process.

(B) The Director shall announce in publications of general circulation in Guam, in top

publications nationally and in leading publications internationally, a Request for Proposal from

Health Care Insurance Providers for health insurance coverage for qualified active employees and

qualified retirees, and foster children, of the government of Guam.

(C) Health Care Insurance Providers that respond and express interest in providing coverage

to qualified active employees and retirees, and foster children, shall, if selected, maintain a bona-

fide office and operations base in Guam and possess a business privilege license to do business

in Guam.

(9) The Negotiating Team upon selection and review of the best available proposal by

participating healthcare respondent(s)/provider(s), which reflect the most economical and beneficial

healthcare insurance proposal plans for government of Guam employees and retirees, and foster

children, shall forward the three (3) highest ranking qualified proposals to I Maga’hågan/Maga’låhen

Guåhan for consideration and selection of the most economical and beneficial health insurance plan,

and transmit to I Liheslaturan Guåhan for its review no later than July 31, and prior to the annual

legislative sessions wherein the upcoming fiscal year budget for the government of Guam is before I

Liheslaturan Guåhan for consideration. Notwithstanding any other provision of law, rule, or regulation,

of the remaining qualifying plans, the employee or retiree may choose one (1) of the remaining

qualified plans, and any difference in premiums shall be paid by the employee or retiree at their own

cost. Notwithstanding any other provision of law, rule, or regulation, the most economical and

beneficial healthcare insurance proposal plan for government of Guam employees and retirees, and

foster children, shall be defined as the lowest cost option.

(10) Within one hundred eighty (180) days of this Act, the Director of the Department of

Administration shall issue a Request for Proposal from qualified individuals or firms to conduct a

feasibility study for a non-profit public healthcare insurance option for Guam.

(11) The RFP shall call for a plan that provides for a level playing field with current and future

private insurers, and the non-profit public healthcare insurance option which pays for care from

individual premiums and co-payments not of the General Fund of the government of Guam.

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(12) Beginning with the negotiations for Fiscal Year 2020, the Negotiating team shall consider

only those companies or other legal entities providing or applying to provide health insurance or the

provision of health care to the Government of Guam whose in-network coverage includes all public

and private hospitals operating in Guam.

(d) No health insurance company or health care provider contracted to provide health care to

government of Guam employees and foster children may deny coverage to the employee or dependents, or

foster children, on the basis of a congenital anomaly. Congenital anomalies shall be covered, subject to

contract negotiations.

(e) Effective October 1, 1986, the contract period for health insurance or provision of health care shall

coincide with the fiscal year of the government of Guam. To that end, the contract period preceding the one

for FY 1987 may be for less than twelve (12) months.

(f) All companies, or other legal entities providing or applying to provide health insurance or the

provision of health care, shall have contracts for services with all government of Guam entities that are

providing health care services to any and all of their subscribers. This requirement shall be met prior to,

and as a condition to, the start of negotiations for the government of Guam Fiscal Year 1999. Any dispute

or controversy between contracting parties shall be submitted to arbitration according to the generally

accepted local practice.

(g) [No text]

(1) All health insurance companies or health care providers contracted to provide health care to

government of Guam employees and retirees, to include foster children, beginning on the first fiscal

year following the inclusion of foster children under the government of Guam health insurance contract

for employees and retirees pursuant to § 4301 of this Article, shall provide to the Negotiating Team,

defined in § 4302(c), and the Office of Finance and Budget, fifteen (15) months of detailed claims

utilization and cost information from period October 1 to September 30 of the previous fiscal year,

and October 1 to December 31 of the current fiscal year, no later than March 1 for the final updated

data for the previous fiscal year in an electronic database file format, such as Microsoft Access or

Microsoft Excel.

(2) The detailed claims utilization and cost information must total in aggregate all the experience

data used to calculate government of Guam insurance rates for the fiscal year following the current

fiscal year. Claims incurred but not received calculations shall be reported separately and must be

derived from detailed claims utilization and cost information submitted and reviewed and approved by

a credentialed actuary from a recognized organization, such as the American Academy of Actuaries or

Society of Actuaries.

(3) The detailed claims utilization and cost information required under this Subsection shall

include only deidentified health information as permitted under the Health Insurance Portability and

Accountability Act of 1996, and shall not include any protected health information, as defined in the

Health Insurance Portability and Accountability Act of 1996.

(4) Detailed demographic and claims utilization and cost information shall include the following

information with a unique contract identifier that links all the following data to the same contract:

(A) type of contract based on all tiers used in program design (EE, EE + SPOUSE, FAMILY,

etc.);

(B) patient demographics, date of birth, gender, relationship to subscriber;

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(C) medical, dental and vision claims, line detail including diagnosis code (ICD9 or ICD10),

procedure codes (CPT, HCPC, CDT), revenue codes, service dates, service provider (name, tax

id, provider id, specialty code, city, state, zip code), plan payments, member payment

responsibility (co-pay, co-insurance, deductible), claim paid date, type of bill and facility type;

(D) prescription drug claims, to include NDC codes, formulary tier identifier, pharmacy

(name, provider id, city, zip code), plan payments, member payment responsibility (co-pay, co-

insurance, deductible) claim paid date, injectable drug indicator, GPI number, ingredient cost,

dispensing fee and rebates; and

(E) any other detailed demographic and claims utilization and cost information as requested

by the Negotiation Team in the Invitation to Bid (ITB) for the fiscal year following the current

fiscal year.

Failure to comply with the requirements of this Section will result in a 2.5% reduction of the quarterly

premiums from the non-compliant health insurance carrier. The information shall be provided

quarterly. The reduction shall be deducted from the premiums due to the carrier in the succeeding

quarter, if the information is not received within forty-five (45) days of the end of the quarter. The

Negotiating Team defined in § 4302(c) at their discretion, at any time during the following fiscal year

health insurance negotiations, may disqualify proposals from health insurance carriers not in

compliance with this Section for their in-force contract.

(h) No health insurance company or health care provider contracted to provide health care to

government of Guam employees and foster children may deny coverage to the employee or dependents or

foster children on the basis of chronic orthopedic deformities. Chronic orthopedic deformities, which may

include orthopedic and external prosthetic devices, including, but not limited to, artificial joints and limbs,

will be covered and may be subject to maximum limitations per annum.

(i) No health insurance company or health care provider contracted to provide health care to

government of Guam employees and foster children may deny coverage to the employee or dependents or

foster children on the basis of blood or blood derivatives. Blood and blood derivatives will be covered and

may be subject to maximum limitations per annum.