Guam § 2903 - Definitions.

§ 2903. Definitions.

In this Article, unless the context otherwise requires:

(a) “Administrator” means the administrator of the Guam Medically Indigent Program.

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(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 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

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

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(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 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 GCA § 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).