Prepaid Health Plans contracting under this Chapter shall guarantee and provide assurances to the Department that all services contracted for shall be readily available and accessible and that further, all medical services covered under the contract which are required on an emergency basis be available on a 24-hour, seven days a week basis, either in the Prepaid Health Plans own facilities or through arrangements with another provider which has been approved by the Department. The Department is hereby directed to establish standards of care and to conduct testing and review procedures to assure compliance with such standards.
It is in the public interest that medical assistance of the proper quality and quantity be provided in the most effective and economical manner consistent with such high quality medical standards. It is further the

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objective of this Chapter that there shall be proper utilization of all health care services.
All administrative powers and duties with respect to Prepaid Health Plans, including determination of per capita payment rates, approval of prepaid health contracts and pilot programs which provide health care services pursuant to prepaid health contracts is hereby vested with the Director of the Department of Public Health and Social Services herein referred to as Director.
The Director is hereby empowered to establish a basic schedule of benefits for prepaid plans conforming to the scope and duration of medicaid health services as set forth in Federal requirements for the territory of Guam to enumerate standards of participation for such Prepaid Health Plans and pilot programs.

In the administration of this Chapter and in the negotiating of contracts thereunder, the Department shall give due consideration to the reputation of the prepaid health organization in providing such benefits, to the accessibility and availability of its facilities and resources for health care to enrolled persons under this Chapter, and to new and innovative concepts in the delivery of health care services.

No contract between the Director and a Prepaid Health Plan shall be approved unless the plan and its facilities meet quality program standards. These standards shall require the Prepaid Health Plan to demonstrate to the Department that it has adequate financial resources, physical facilities, organizational and administrative capacities, and a sound program design to discharge its contractual obligations.

The Prepaid Health Plan will maintain financial records in accordance with applicable Federal guidelines and will also have annual audits performed by an independent certified public accountant. Certified financial statements shall be filed annually as soon as practical after the close of the plan’s fiscal year and in any event within a period not to exceed one hundred twenty (120) days thereafter. For good cause, the Department may grant exceptions to the time within which annual financial statements are to be submitted to the Department.
The Prepaid Health Plan shall be liable for all valid out-of-area emergency services which are required by the contract and rendered by another provider. Payment for such services shall cover treatment of emergency conditions provided plan has been notified within seventy- two

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(72) hours of occurrence until such time as the patient may reasonably be transferred to the Prepaid Health Plan’s facilities.
The Prepaid Health Plan shall establish procedures for continuously reviewing the quality of care, the utilization of services and facilities and costs. Information derived from such review shall be made available to the Department.

If the enrollee has an unresolved grievance, a fair hearing shall be made available under appropriate provisions of the Government Code of Guam to resolve all grievances regarding care and administration of the plan. Findings and recommendations of the Director based on the results of the fair hearing shall be binding on the plan and the enrollees.
The Director shall report annually to the Legislature on the experience with the prepaid plan with specific reference to consumer satisfaction and dissatisfaction, quality and utilization.
SOURCE: GC § 9942.