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While there is concern among the local medical community about the government of Guam self-insured health plan, including whether payment will be made to providers on time, representatives from companies chosen to serve as third-party administrators for GovGuam said payments will be handled by the companies, not the government, and that payments will be timely.
The Office of the Governor announced Tuesday that GovGuam will fully self-insure for its fiscal year 2024 group health plan. GovGuam is already self-insured for pharmaceutical and dental coverage, so next fiscal year will bring medical benefits into the fold.
Third-party administrators will collect premiums from GovGuam units, which will be remitted to a fund to pay for the coverage. GovGuam also will pay a fee to the administrators.
SelectCare was named the administrator for medical and pharmacy benefits, and for coverage of foster care children. NetCare will serve as the administrator for dental benefits.
News that the government will move completely to self-insurance caused some concern in the medical community, with some providers cautioning that they may opt out of serving patients covered by GovGuam, according to Dr. Hoa Nguyen, a principal partner and physician at the American Medical Center. AMC has experienced delays receiving payment from the Department of Administration, and that is a concern shared among providers, Nguyen has said.
DOA Director Edward Birn has said publicly that GovGuam will not pay providers directly, but will reimburse payments made by administrators. The self-insurance model also won’t affect contracts the administrators already have with providers in their networks, Birn said.
Alleviating concerns
Frank Campillo, the health plan administrator at SelectCare, said the company will process claims in the same manner it currently processes all claims, and will draw from the government account to fund the self-insured claims.
“Integrity and timeliness of payment to the medical providers is important to us, and something that should be carried forward in the new self-funded program by GovGuam,” Campillo said. “Payment to providers or reimbursements of claims to members are handled by the third-party administrator and funded by GovGuam. We will conduct a providers’ briefing in the weeks ahead in order to address and alleviate the concerns that have been voiced by a few providers.”
Jerry Crisostomo, the plan administrator at NetCare, said provider payment should be “very transparent” under the self-funded model, as it was under the insurance carrier model, echoing that providers will be paid by the third-party administrators, not GovGuam, “and in the same timely manner.”
As for the claims process, Crisostomo essentially said the same as Campillo, that providers will submit claims directly to NetCare, which will process claims in accordance with its benefit policy and Guam’s prompt payment law. The law requires claims to be paid no later than 45 days from the received date of a claim, Crisostomo said.
NetCare will transmit a claims paid report directly to DOA, listing the claims received and processed for payment. DOA will then reimburse and remit payments to NetCare, Crisostomo added.
“NetCare has provider agreements with all local dental providers under both our fully insured and self-funded markets. Payments are made the same way. There’s no difference other than an employer funding their claims under the self-funded plan and the (administrator) paying the claims on behalf of the client as opposed to paying premiums to an insurance company, who then pays the claims to providers,” Crisostomo said.
‘Good business sense’
Both SelectCare and NetCare have served as insurance carriers for GovGuam in the past.
SelectCare also served as the administrator for GovGuam’s self-insured dental plan in fiscal 2022, Campillo said. There were no issues with the funding mechanism then, and the company is not aware of any delays in funding the current self-insured plan for pharmacy and dental benefits, he added.
If GovGuam somehow doesn’t have the money to reimburse a third-party administrator, that will be handled between them, through monthly reporting, including that of unpaid claims, Crisostomo said. But he added that his company doesn’t anticipate that will be an issue.
“Under the fully insured program – using an insurance carrier – GovGuam was responsible for remitting premium payments to the insurance carrier to settle claims. Under the self-funded program, GovGuam will now fund the claims in order for the (third-party administrator) to pay claims directly to the provider. It is nonsense to think GovGuam will not have the money to fund its claims,” Crisostomo said.
“We have every confidence that GovGuam will always meet its financial obligations to its employees and retirees,” he added. “We support Gov. Lou Leon Guerrero’s bold decision to transition GovGuam’s medical, dental and pharmacy program to a self-funded plan. Over 65% of large employers (100 or more employees) in the U.S. are self-funded. This just makes good business sense.”
