COMMONWEALTH Healthcare Corporation Chief Executive Officer Esther L. Muna on Monday said the CNMI Medical Referral Program focuses on coordinating access to care for patients in an equitable and cost-efficient manner.
She said it is a “program that provides and coordinates care, coordinates the services that can be provided off-island, and that includes transportation [and] lodging. We are not considered insurance. I just wanted to clarify that.”
She added, “When you are sent off-island, we’re just bringing you there; we’re bringing the access to you, for you to be able to see [a provider] and get the treatment [you need], but it doesn’t mean that we’re going to pay for the care.”
She said the program identifies off-island providers who may be able to assist the patient with services not offered on-island.
It also includes looking into whether or not a patient’s health insurance is accepted by off-island providers and pharmacies.
CNMI Medicaid Agency Acting Director Vicenta Borja said the CNMI has contracts with a number of providers on Guam, but none with the pharmacies there.
CHCC CEO Muna said Guam pharmacies are not accepting Medicaid at this time, but there have been ongoing discussions with Centers for Medicare and Medicaid Services Region IX to address this issue.
“All providers have a decision to make, whether or not they want to sign up to become a Medicaid provider,” Muna said. “Not every provider wants to be a Medicaid provider. We seek providers that are willing to take our patients. Sometimes, it’s very limited in Guam, so we often send patients [elsewhere],” she added.
“In order for the CNMI Medicaid to pay for services outside of the CNMI, contracts need to be executed,” Borja said. “With Guam, it is mandatory. [For] any patient [who] will be sent to Guam, a contract must be in place in order for us to reimburse the providers. However, if patients are referred to California or Hawaii or any of the U.S. states, we don’t necessarily need a provider agreement, as long as [the patients] are enrolled with their state Medicaid.”
She said, “There is a limited number of providers on Guam who are contracted with us. However, we are trying to expand, and we are working closely with them…. Right now, we don’t have any contracts with the pharmacies on Guam.”
Co-payments are common, and patients will likely need to pay out-of-pocket for some costs.
“There are a lot of things that we’re trying to do to address the gaps and make sure that this problem does not continue,” Muna said. “What we’re trying to do, really, is to ensure that the medical referral program is sustainable and is available for everyone.”
She added that when Medicaid can’t pay for certain services, then the medical referral program needs to find a way, based on their regulations, to minimize the burden on the patients.
Muna said the program must follow its regulations.
“One of the reasons why the program is in the hands of CHCC is to ensure compliance with the regulations. As some of you may have read or recall, there was an audit on the medical referral program, and it is definitely essential for CHCC to ensure compliance with those regulations,” she added.
“We understand that Medicaid has its own regulations. We’re considering maybe making a change to the [CNMI] plan. That is up for discussion right now. We’re trying to figure out how we can help the patients, but ensure that we still follow the law [and] the regulations,” Muna said.
“We will assist you as much as we can, and we’ll see how we can help you,” she added.
