Off Guam Medical Care and Services

(a)Prior Authorization is required before any MIP Program recipient may receive care and services at an off Guam treatment facility.

(b)Failure to obtain an authorization prior to the rendering of care and services will result in the denial of assistance from the Program.

(c)Off Guam medical care and services are to be provided in accordance with the Program benefits outlined in § 2907.

(d)Off Guam medical care and services are provided to MIP Program recipients in accordance with the following:

(1)Eligibility. Program standards are in effect with regard to income, resource and residency requirements for off Guam care.

(2)An applicant must not have voluntarily discontinued the applicant’s insurance coverage within six

(6)months prior to application to the Medically Indigent Program. CH. 2 DIVISION OF PUBLIC WELFARE

(3)Those with insurance must continue with their insurance coverage.

(e)[No text]

(1)Medical Review. All off Guam referrals will be reviewed by the Administrator after the applicant is found eligible and all necessary documents have been submitted. Referrals will be reviewed to determine that the treatment is medically necessary, significant beneficial outcomes affecting the patient’s quality of life is expected and the care is not available on Guam. The Administrator shall consult with the attending physician and any other specialists as may be required.

(2)Advance Payments for Medical Services. In order to expedite acceptance of Medically Indigent Program

(MIP)clients by facilities in California, Hawaii or Manila for medical treatment approved by the MIP, the Director of Public Health and Social Services may advance payments for said medical treatment, and may establish escrow accounts for immediate and advance payment of medical treatment at those Joint Commission Accredited hospitals determined by the Director to be best able to serve Medically Indigent Program clients.

(f)Coverage. The Program shall cover off Guam care and services subject to all benefit limitations and exclusions if the off Guam medically necessary care or treatment is provided at a contracted facility or a non-contracted facility, if care is not available at a contracted facility when referral criteria are met and care or treatment is not available on Guam.

(g)Air Transportation. Round trip air transportation will be provided to an eligible Program patient when all other criteria for off Guam care have been met. One

(1)parent, or guardian, if the parent is unable to accompany the child, will be covered if the patient is a minor, seventeen

(17)years of age or below. Air transportation and per diem will also be provided for one

(1)medical escort (registered nurse or physician). If more than one

(1)escort is required, client shall cover the cost for additional escorts.

(1)Agreements for Wholesale Purchase of Airline Tickets Authorized. Funds appropriated to the Department of Public Health & Social Services for the Medically Indigent Program and funds allocated under the Medicaid program may be used for Off-Guam medical care and services provided for in this Section. The Director of Public Health and Social Services is authorized to enter into agreements with air carriers for the wholesale purchase of airline tickets for roundtrip air transportation and may obligate such funds as are necessary from the funding sources provided for in this Section to enter into such agreements.

(2)Additional Medical Escorts Authorized. At the discretion of the Director of Public Health and Social Services, additional medical escorts may be approved for air transportation and per diem costs for patients requiring acute care.

(h)Supplemental Assistance for Off Guam Care Upon Exhaustion of Insurance Benefits. A patient may be covered under an existing insurance Program and may be eligible to apply to the Medically Indigent Program for supplemental assistance upon exhaustion of benefits, and subject to all benefit limitations and exclusions.

(i)Off Guam services not covered:

(1)elective cosmetic surgery;

(2)experimental treatments;

(3)fertility procedures, sterilizations, abortions;

(4)off Guam living expenses;

(5)organ transplants; CH. 2 DIVISION OF PUBLIC WELFARE

(6)other services covered by local or Federal government; and

(7)off Guam emergency medical services.

(j)Limitations and Exclusions. All off island services are subject to the stated benefit limitations and exclusions outlined in § 2912 through § 2913.