Responsibility. — Guam Code § 6102

§ 6102. Responsibility.

The Department shall, in carrying out the intent of this Chapter,

contract with a multispecialty group practice of an individual practice

association through a Prepaid Health Plan to establish pilot programs which

demonstrate the value or lack thereof of such a program in delivering or

financing health care services in such a manner. Each pilot program be for a

specified duration not to exceed four (4) years and each pilot program shall

be evaluated annually for its efficiency, effectiveness and quality. The

Department shall pursue the feasibility of establishing the following as pilot

program:

A per person risk assuming contract with one (1) or more

organization which provide payment to a specified class or classes of

providers.

Persons eligible for services under the public assistance program

shall be assigned by the Department to a Prepaid Health Plan which

affords any qualified medicaid provider within the territory of Guam

an opportunity to participate in the plan under reasonable restrictions

approved by the Department; provided, however, such persons shall be

entitled to request and receive a medicaid card if assignment to a plan

does not meet with their satisfaction.

For purposes of this Section "risk assuming" means the pilot program

contractor agrees to assume the risk of utilization of services or costs of

services, or both.

The Department shall establish, through contracts, health service

delivery systems as pilot programs to determine whether high-quality

comprehensive medicaid benefits can be provided at a reasonable cost on a

prepayment basis on such a system. The pilot programs shall have at least

the following characteristics:

The programs shall be operated either by the Department directly

or through contracts with Prepaid Health Plans.

The programs shall enroll medicaid recipients and be funded by

the Department on a prepayment capitation basis. Such rate of

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payment shall be determined annually and shall be ten percent (10%)

less than valid claims incurred by the Department for covered medic-

aid recipients projected on an annual basis as reflected by the accrued

average monthly claims for the previous six (6) months plus all

anticipated increases in costs in the contract year. The rate shall not

include any costs of the Department for claims or administrative fees

to fiscal intermediaries. The per capita amounts determined shall be

based on sound actuarial data and be recognized to vary between the

categories of aid to families with dependent children, aid to the totally

disabled, aid to the blind, old age security or such other categories as

may be determined by the Director of the Department.

The programs shall provide the full range of services offered

under the public assistance program and shall meet all statutory

requirements and all regulatory and contractual requirements

established by the Department for the program.

The programs shall emphasize the innovative use of health

personnel including mid-level medical, nursing and dental profes-

sionals in ambulatory settings.

Medicaid recipients enrolling in a pilot program pursuant to this

Chapter shall be offered a choice of qualified primary care physicians

employed or under contractual arrangements with the Prepaid Health

Plan to be the recipients' designated primary care physicians.