Member Handbook 2021101409

See how far we’ll go.
Member
H A N D B O O K
staywellguam.com 1
STRENGTH
and STABILITY
CONTENTS
StayWell currently serves private business employees and families in Guam
MEMBER RIGHTS &
and the Commonwealth of the Northern Mariana Islands (CNMI). We are
pleased to welcome you to our family of members.
RESPONSIBILITIES 2
BENEFITS OF THE
Our company is a long-running business backed by Island Home
STAYWELL PLAN 3
Insurance Company (IHIC), a locally owned insurance company. IHIC is
reinsured by Sirius America Insurance Company (Sirius America), a U.S.- ACCESSING STAYWELL
based insurer and reinsurer focused primarily on Property and Accident & CARE
Health coverages.
This handbook explains all the benefits of being a member. It can also be
HEALTH MANAGEMENT
PROGRAM
9
your quick reference guide to frequently asked questions. We encourage
you to contact our Customer Care Department for further advice on your
COSTS & CLAIMS 18
specific health plan, changes or addendums. You may visit our website at GENERAL
www.staywellguam.com for soft copies of our Member Handbook, Notice INFORMATION 20
of Privacy Policy (NPP), Claim forms, Enrollment forms, and Health
Management information. You may also register on the StayWell Access
GLOSSARY 26
web portal to view your current coverage and benefits, member ID, and YOUR RIGHTS 28
processed claims.
As a StayWell subscriber, you will also have access to the following benefits
at no additional cost:
• Group Fitness Classes at facilities on Guam
• Health Risk Assessment
• Nutrition Education
• Online Health Activity Tracker
• Healthy Living Guidelines Streaming Videos
Once again, welcome and thank you for taking this journey
towards better health care and customer satisfaction with
StayWell Insurance.
See how far we’ll go.
This handbook is for informational purposes only. Its contents are subject to the provisions of the StayWell/IHIC contract. In the event of a discrepancy 1
between this handbook and the contract, the terms of the contract will prevail Rev. 10/2021
MEMBER RIGHTS and
RESPONSIBILITIES
Member’s Rights
As a valued StayWell Member, you have the right to:
• Be treated with respect, consideration, and dignity regardless of race, religion, national origin, gender, cultural
background, educational or economic status, age, sexual orientation, type of illness, or mental or physical
disability.
• Privacy and confidentiality of health information. Member disclosures and records are treated confidentially.
Members are given the opportunity to approve or refuse the release of records except when required by law.
• Receive information about the out-of-pocket share and fees you must pay.
• Receive information about your plan benefits, coverage, limitations, and exclusions.
• Be advised by a health care professional on how to schedule appointments and get health care during and after
office hours, and for emergent care. This includes continuity of care.
• Obtain medically necessary emergency and urgent care.
• Know your access to out of area care and covered services, as applicable.
• Access the network for primary and specialty care, including behavioral/mental health care.
• Select and change providers within your plan’s network. Refer to the provider directory for a list of all participating
providers.
• Know the names, credentials, and qualifications of healthcare professionals providing your health treatment.
• Talk about appropriate or medically necessary care options, regardless of cost or coverage.
• Be informed if a healthcare professional plans to use an experimental treatment or procedure.
You have the right to refuse to participate in research projects.
• Complete an advance directive, living will, or other directive, and to place that directive in your medical record.
• Actively participate in decisions that relate to your health and your medical care through discussions with your
health care provider or through written advance directives.
• Receive complete information concerning your evaluation, diagnosis, treatment, and prognosis.
• Receive interpretive services, as necessary.
• File complaints or grievances about the plan, your provider, or care you receive.
• File an Appeal for reconsideration of an Adverse Determination of a health service request or benefit.
• Have any questions or concerns about your rights and protections answered by us.
Member’s Responsibilities
As a valued StayWell Member, you are responsible to:
• Treat all healthcare providers, staff, and others with respect.
• Provide an accurate health history, including information about medications and over-the-counter products,
dietary supplements, and allergies or sensitivities.
• Follow the treatment plan prescribed by your provider and to participate in your care.
• Inform your provider about any living will, medical power of attorney, or other directive that could affect your
care.
• Accept personal financial responsibility for any charges not covered by insurance, if applicable.
• Be familiar with your coverage. Pay your premiums and any copayments, coinsurance, and deductibles you may
owe.
2 This handbook is for informational purposes only. Its contents are subject to the provisions of the StayWell/IHIC contract. In the event of a discrepancy
BENEFITS
of the STAYWELL PLAN
• COMPREHENSIVE medical and dental Benefits, including
preventive care
• FREEDOM to choose any medical and dental care provider
• HEALTH MANAGEMENT PROGRAM that includes wellness,
fitness and disease management
• DEDICATED Customer Care
• EXCELLENT StayWell service
• UNLIMITED Lifetime Coverage
• 100% COVERAGE after Annual Out of Pocket Maximum is met
• 100% COVERAGE for inpatient care at the Centers of Excellence
• 100% COVERAGE for formulary prescription by mail for
maintenance medications
• 100% COVERAGE for preventive health services
• AIRFARE BENEFITS available when qualifications are met
ACCESSING STAYWELL CARE

PREFERRED PROVIDER transfer your primary care services behavioral/mental health care
ORGANIZATION within the StayWell network of through direct access to the
providers. Network providers are behavioral/mental health provider
As a Preferred Provider
under contract to provide certain or through a recommendation
Organization (PPO), the StayWell
services at reduced rates. Payment from your primary care physician
Plan allows you to choose any
for all treatments you receive from or other treatment providers.
hospital, physician, or other
network providers are subject to StayWell does not require pre-
healthcare provider you wish.
those contracted rates. certification for consultations. If
However, when you use a hospital/
therapy is recommended for you,
facility or provider who is part of
StayWell may require prior
the StayWell PPO network, your
ON ISLAND CARE authorization. Please refer to the
claims will be processed based on
StayWell has a large local provider pre-certification process section of
specifically negotiated reduced
network. StayWell contracts with this handbook for further detail.
rates. These rates mean out-of-
pocket savings to you because over 95% of Guam and CNMI’s
your cost is based on lower fees. physicians, including the staff of
Evergreen Health Center, American URGENT CARE – AFTER
Your Coinsurance and Copayment
Medical Center, The Seventh Day HOURS
for services rendered at a
Participating Provider is based on Adventist Clinic, IHP, and the Guam For information on where to seek
Eligible Charges and is Radiology Consultants. after-hours care, you may view
accumulated towards the Annual StayWell’s Provider Directory. You
Out of Pocket Maximum. You don’t can also call your provider for
have to choose a particular primary BEHAVIORAL/MENTAL information on receiving after-
care physician, nor are you HEALTH ACCESS TO CARE hours care. Urgent Care (After
required to obtain approval before As a StayWell member, you have Hours) is needed when you have a
seeing a specialty care physician. access to behavioral/mental health health problem that requires
You’re also not required to seek a and substance abuse treatment attention right away, but your life is
prior authorization if you decide to and services. You may access not in danger. Urgent Care is not
PROVIDER APPOINTMENT AVAILABILITY STANDARDS
Emergency Care. It is usually not StayWell Insurance has appointment availability standards for primary care
life-threatening, yet you cannot providers (PCPs) and specialists. The requirements apply to routine, urgent,
wait for a visit to your Primary Care and after-hours care. These standards will help ensure you receive timely
Physician (PCP). Some examples access to care.
of Urgent Care include:
• A child with an earache who Medical Care Appointment Type Standard
wakes up in the middle of the Emergencies Immediate
night,
Urgent Care 24 hours
• A sore throat,
Routine Symptomatic Cases Within 1 week or 5 business days
• A sprained ankle, or,
• A bad splinter you cannot As soon as possible but no
Routine Non-Symptomatic Cases
longer than 30 days
remove.
After-Hours 24 hours/7 days a week
Behavioral Health
EMERGENCY CARE Appointment Type
Standard
An emergency is when you have a Life-Threatening
medical condition with symptoms 24 hours/7 days a week
Emergency Care
severe enough that the lack of Non-Life-Threatening
immediate medical attention could Within 6 hours
Emergency Care
result in serious danger to your
health, or, in the case of a pregnant Urgent Care Within 48 hours
woman, the health of her unborn Routine Care Within 10 business days
child. If you think you have an
emergency, call 911 or go to the
nearest hospital. You do not need a
doctor’s approval. Services will be services for depression, behavioral/ receiving prescriptions within the
covered. Some examples of mental illness, substance abuse, or following channels:
Emergency Care include: emotional questions. Some
• A broken bone, examples of behavioral/mental Retail Pharmacy
• Bleeding that will not stop, health emergencies include: Medimpact’s participating
• Acting on a suicide threat, pharmacy network includes more
• Severe chest pain, than 64,000 participating
• Drug overdose, • Homicidal or threatening
pharmacies, including regional and
behavior,
• Trouble breathing, national chains as well as
• Self-injury needing immediate independent community
• A gun wound, medical attention, pharmacies. The Choice 30 benefit
• Poisoning, or, • Severe impairment by drugs or allows you to obtain a 30-day
• You are pregnant, in labor, and/ alcohol, or supply of covered medication. The
or bleeding Choice 90 pharmacy benefit will
• Highly erratic or unusual
allow you to obtain a 90-day
behavior that indicates very
supply of formulary maintenance
unpredictable behavior
BEHAVIORAL/MENTAL medications through local and
HEALTH EMERGENCY nationwide retail stores at a
You should call 911 if you or your PHARMACY/MEDICATION reduced out-of-pocket expense.
dependent is having a life- To help manage the increasing Specialty Pharmacy
threatening behavioral/mental costs of prescription drugs,
health emergency or go to the Your Specialty Pharmacy is
StayWell has secured the services
nearest hospital. As a StayWell Medimpact Direct Specialty. Our
of Medimpact Healthcare Systems,
member, you have access to specialty pharmacies were carefully
Inc., a pharmacy benefit manager
behavioral/mental health services chosen to provide you with
(PBM) based in San Diego,
and do not have to wait for an convenient delivery and
California. Together, we aim to
emergency to get help. Call personalized service. The Specialty
provide you with high quality of
StayWell’s Utilization Management program supports members with
care. Medimpact’s pharmacy
department for someone to help complex health conditions who
network provides flexibility in
you or your dependent obtain need injectable medications,
MEDIMPACT’S online tools allow you to:
• Order new prescriptions or transfer from retail pharmacy
• Refill mail-order drugs or renew expired mail prescriptions
• Review estimated copay amount, last order status, and date for
next refill
• Get reminders and alerts via phonecall, email or two-way text
• View and sort your list of mail-order drugs
• Manage account information
• Make payments
medications with strict compliance available at www.medimpact. refilled, your payment method and
requirements, or who have special com. your preferred shipping address.
storage needs. • Send your order form to
Medimpact Direct at PO Box
Mail Order Pharmacy OFF ISLAND CARE - CENTERS
51580 Phoenix, AZ 85076-
You can obtain a 90-day supply for 1580. OF EXCELLENCE
ongoing formulary maintenance StayWell’s extensive off island
medication(s)– prescriptions you 3. Sign in to website network of providers includes
take on a regular basis to manage Sign in to www.medimpact.com or outstanding medical facilities
conditions like arthritis, high blood their mobile app and choose located in California and the
pressure, asthma, diabetes, or high "Request a Prescription" on the "My Philippines.
cholesterol– through the mail Prescriptions" page and follow the The Centers of Excellence (COE)
order program with Medimpact instructions. are chosen for their outstanding
Direct. With mail-order, you can
Once your new prescription is facilities, services and regional
have your prescriptions delivered
processed, track orders at www. location. These Centers offer
right to your home and
medimpact.com or on their mobile significantly discounted rates to
coinsurance/copayment is waived.
app. StayWell members. In cases of
inpatient care, members are
Set up new maintenance mail
For prescription refills: covered at 100% of Eligible
order prescriptions:
Charges, subject to Benefit
1. From your doctor 1. Order by phone maximums.
Your doctor directly submits your Call the Toll-Free number (855) When you require off island
prescription electronically or faxes 873-8739 for Medimpact’s refill treatment you may be eligible for
your prescription to: 1-888-783- phone service or to speak to a round-trip airfare if the following
1773. Medimpact can only accept representative. criteria are met:
faxes from doctors, not patients. • For refills please be ready to • StayWell is your primary
Once your prescription is received, provide your prescription refill insurance carrier
you will be contacted to confirm number(s), cardholder ID,
details. Medimpact will not ship • You have been a StayWell
year of birth, and your Visa,
until you confirm that you want the member for at least six
Discover, or MasterCard for
medication(s). consecutive months
payment.
• You obtain a written pre-
2. Mail your prescriptions 2. Order online certification from StayWell
Mail your prescription(s) to Register for online account access • You have a catastrophic illness
Medimpact with a completed with your member identification that requires any of these
Medimpact Direct Mail Order Form. number from your member ID medical procedures: open
Please enclose payment details card, first name, last name and date heart surgery, angioplasty,
with your order. of birth. Once logged in, select the cardiac catheterization,
• Download a mail order prescription you need to have endarterectomy, oncology
form in PDF format which is
surgery, aneurysmectomy, • Participating Providers – may or may not be required from
pneumonectomy, intracranial the doctors, laboratories, the PCP prior to a consultation.
surgery, treatment for acute pharmacies, and other health StayWell does not require pre-
leukemia, gamma knife, or care providers in the StayWell certification or prior approval for
NICU Level III care network consultation with on-island
• Service is scheduled to be • Centers of Excellence – participating specialists and
provided at a Center of the off island hospitals and emergency room services as well
Excellence ambulatory surgicenters as consultation for a second
affiliated with StayWell opinion.
Round-trip commercial tickets to
the Center of Excellence are • Ways to Save Money – advice
purchased at the lowest economy on how the health care Out of Network Referrals
fare available inclusive of medical choices you make can reduce If a PCP refers a member to an
discounts. Coverage of airfare is your out-of-pocket expenses out-of-network specialist, he/she
subject to review by StayWell and Whether it is on island or offisland, must secure a pre-certification of
will depend on the submission of StayWell requires that you obtain a eligibility and a prior authorization
required documents (e.g. operative written pre-certification from the for the contemplated services.
report, boarding pass, proof of UM-IC Program specialists before Coverage will be based on the
purchase). Proactive airfare receiving care. non-participating benefit, which
coverage may be granted only if means higher out of pocket
there is a written request from a In an emergency, pre-certification
is not required before receiving expense for the member. Your
COE physician that a qualifying coinsurance at a Non-Participating
procedure will be performed. An care.
Provider does not accumulate
off island referral does not When accessing care, please note towards your annual out-of-pocket
guarantee airfare coverage. StayWell’s policy regarding medical maximum.
In the event you purchase the necessity for treatment and care.
seat(s), StayWell may reimburse no To keep medical costs at an
more than what it would have paid affordable level, StayWell only pays Pre-certification Process
had it purchased the seat(s) in for Services that are Medically
Pre-certification is a formal process
advance. In no event will StayWell Necessary, as defined in the Plan
where a provider obtains eligibility
reimburse for any seat(s) purchased Contract. Cases that are Medically
information and prior authorization
with frequent flyer miles. Necessary require the most
or approval from StayWell’s UM-IC
appropriate and economical use of
Department before performing a
services and facilities. The overuse
certain treatment or providing
UTILIZATION MANAGEMENT– or unnecessary use of costly or
covered services such as:
INFORMED CHOICE ineffective medical services is
discouraged and will not be paid. • Hospital Admissions
PROGRAM
The fact that a doctor may • Ambulatory procedures
StayWell’s Utilization Management-
prescribe, order, recommend or • Surgery center procedures
Informed Choice (UM-IC) Program
approve a service or supply does • Certain outpatient office
helps you secure excellent medical
not in itself make it Medically procedures
care, both on island and offisland,
Necessary or make the charge an
for the least out-of-pocket • Diagnostic Imaging
allowable expense. Should medical
expense. The program’s staff are procedures
necessity be unclear, StayWell’s
medical service specialists
medical coordinators will evaluate • Home Health Care
knowledgeable about StayWell’s
the case, based on available • Hospice Care
pre-certification procedures and
information, before particular
off island coverage. • Durable Medical Equipment
services are performed.
Without compromising the • Certain Medications
confidentiality of your medical The UM-IC Department reviews
condition, the Customer Care staff Referral Process and prior authorizes physician’s
can assist you in making orders based on eligibility, plan
The Primary Care Physician (PCP)
appropriate choices about health benefit coverage, and medical
initiates referrals to specialty or
care such as: necessity. The UM-IC Department
sub-specialty services as they
• Allowable Benefits – the tests, deem necessary. Depending on the follows nationally recognized
supplies & treatment options specialty clinic’s protocol, a referral standard guidelines in making
covered by StayWell
In accordance with ERISA, StayWell follows the following timeframes for THE STAYWELL NETWORK
SAVES
UM determinations:
Review Type Standard Timeframe of Notification
Urgent pre-service 72 hours
Non-urgent/routine
pre-services
15 days YOU
Concurrent review 24 hours MONEY!
Post-service review 30 days
It’s good to discover ways
you can cut the cost of
clinical determinations. Any up your pre-certification. your health care without
adverse determination for medical reducing the quality of care.
• Hand carry your StayWell pre-
necessity is reviewed by a health Here’s an easy way you can
certification.
professional with training relevant do just that.
to the request. These guidelines are • Hand carry all imaging
available to the member and to the films, pathology slides/ You will save money
providers upon request. specimens, medical records simply by using StayWell’s
and referral papers to doctors Network of Participating
A complete Pre-certification appointments. Providers. StayWell’s
request can be faxed to the UM-IC
Department at (671) 477-2464. For • If you are unable to make it network includes doctors,
immediate processing, the to a scheduled appointment, dentists, chiropractors,
requesting provider must complete notify the doctor’s office mental health professionals,
the following: for cancellation and re- hospitals, pharmacies,
scheduling. Otherwise, you laboratories, optical firms,
• Accomplished StayWell’s Pre- may be charged a no-show
certification form private home health care
fee.
agencies and other medical
• ICD10 and CPT codes with • If you will be out of the
description facilities, in the Service Area
Service Area for more than and outside the Service
• Complete pertinent medical 60 accumulative days, submit
Area, which have agreed to
records to support the request a request for extension of
benefits outside the Service
provide services to StayWell
Emergent cases do not require members at substantially
prior authorization. Payment of Area, together with the
treatment plan of your doctor, reduced rates.
claims for services rendered as
Emergent is subject to review to StayWell’s Customer Care The overall cost of your
according to StayWell’s health plan Department prior to the 60th
health care is much less
benefits, member eligibility, day.
when you go to a provider
exclusions, and medical necessity • When you return to Guam, INSIDE the network than
at the time the services are bring back all materials that
when you go OUTSIDE the
rendered. will help facilitate continuity
network. As a result, your
The absence of a prior of care.
out-of-pocket expenses are
authorization may result in denial • Call the StayWell toll free greatly reduced. In some
of claims. number at 1-866-782-9955
cases, your Coinsurance/
or email offislandreferral@
staywellguam.com, if you
Copayment is waived
TIPS FOR OFF ISLAND CARE have questions regarding your altogether, and you pay
coverage. nothing! However, if you
• Before your departure, you or
your authorized representative choose to go OUTSIDE
may call or visit the Customer the network for care,
Care Department at the you pay much more for
StayWell office to coordinate Coinsurance/Copayment
your off island care and pick for service.
TRAVEL ALLOWANCE
StayWell members enrolled in
certain plans are eligible for a
one-time reimbursement of up to
$500 when traveling roundtrip
from member’s place of residence
(Guam or Saipan) to Centers of
Excellence in the Philippines for
specific procedures. Below are the
terms and conditions of StayWell’s
Travel Allowance benefit for
members:
a. StayWell members may utilize
their annual Travel Allowance
benefit for the following quali-
fied procedures after pre-cer-
tification has been issued:
• Arthroscopy ii. Reimbursement up to f. In the event that member will
• Cataract Extraction $500 for airfare/lodging be traveling to Philippine COE
• Cholecystectomy (Open/ iii. No reimbursement will be for two (2) different qualifying
Endoscopic) made for use of airline conditions (i.e. heart surgery
• Colonoscopy mileage and/or for and colonoscopy), only one
• Cystoscopy/Cystoure- complimentary lodging (1) benefit (either airfare or
throscopy travel allowance) will be paid.
iv. Reimbursement for
• Esoagogastroduodenos- lodging up to 5 days
copy (EGD) maximum. STAYWELL ACCESS
• Extracorporeal Shock
v. Reimbursement for travel WEB PORTAL
Wave Lithotripsy (ESWL)
• Transurethral Resection of allowance will follow StayWell Access is an online web
Prostate (TURP) existing Paid to Claimant portal that gives members the
b. Members are eligible for one reimbursement process. ability to access coverage, benefits
(1) roundtrip Travel Allowance d. Eligibility for the Travel Allow- and claims information online
benefit per year. ance benefit will be based on 24-hours a day, 7-days a week.
c. The Travel Allowance benefit current airfare benefit criteria Members can view the following:
is paid via reimbursement to (with the exception of qualify-
• ID card
the member for eligible ing conditions) and are as
• Current coverage and benefits
charges upon submission of follows:
• Processed health claims
original, official receipts and • StayWell must be the
• Deductible and coinsurance/
documentation as listed Primary Insurance Carrier
copayment
below: • Patient must be a StayWell
member for 6 consecutive • Prior authorization requests
• Airfare Receipt (lowest
months • Forms
economy-class, direct
roundtrip to Centers of • Procedure must be done
Excellence in the at a StayWell Philippine Follow these instructions to
Philippines from your Centers of Excellence connect to StayWell Access:
place of residence) • Precertification must be 1. Visit www.staywellguam.com
• Airline Boarding Passes issued prior to travel.
2. Click on ACCESS at the top
(to and from COE in • Member must be going to
of the page
the Philippines) a StayWell Philippine
Center of Excellence for 3. Select Member
• Official Hotel Receipt 4. Click on Register Account
i. All official receipts and specific conditions as
noted in section a. 5. Read the License Agreement
documents must have
claimant’s name and must e. Members may avail of either 6. Select Accept and click Next
be submitted within 30 their Travel Allowance or 7. Enter required information
days of date of return to existing airfare benefit within and follow instructions to
place of residence. the same year provided all create login
qualifying conditions are met.
HEALTH MANAGEMENT PROGRAM
StayWell Insurance is proud to offer StayWell’s member population. To Portability and Accountability Act).
our EnjoyLife Program, an exclusive ensure and improve program An individual report is generated at
Health Management Program. efficacy outcomes are measured the completion of the assessment,
EnjoyLife delivers a comprehensive, and assessed through a which summarizes the member’s
proactive and integrated approach collaboration of program staff and overall health and risk levels for
to help StayWell members to partners. Below are the detailed specific risk factors to help the
manage their well-being and descriptions of each program member identify areas for possible
improve health outcomes. Our component and how each is improvement, specific
exclusive program is categorized administered. interventions, and programs that
into three key components of will help meet their individual
wellness, fitness, and chronic needs. Group reporting features
disease management. Each WELLNESS are also available to help employers
component is designed to help Health Risk Assessment address the needs of their
members get healthy, stay healthy workforce. Members 18 years old
and ultimately enjoy life! Services A Health Risk Assessment (or HRA) and older are eligible to complete
offered in each program is a yearly screening tool for the online HRA.
component are provided by our identifying an individual’s lifestyle
behavior risk through a personal Secured login information is
staff and partners who have distributed upon request through
acquired the appropriate health survey with questions based
on demographics, biometric and the subscriber’s respective Human
credentials, education, training, Resources Department, or they
skills, and continuing education physical health information,
exercise and nutrition patterns, may call our Health Management
necessary to oversee program Department at (671) 477-5091 ext.
administration and specific conditions of personal risk, stress
and mental status, tobacco and 1185 to obtain login information.
responsibilities within their role of Members who do not have access
the program. Each component alcohol use, productivity, and
readiness to change. Any personal to the internet, computer, smart
takes into consideration the phone or device can make an
medical, psychological, social, health data collected is protected
under federal law (Health Insurance appointment to complete the
cultural and occupational needs of
Nutrition Education
StayWell Members have access to
nutrition education and this is
provided to our members through
the following methods:
a. At a worksite, this is usually
done as a 'Lunch-and-Learn'
activity. StayWell invites a
Clinical Nutritionist, Dietitian
or medical professional to
provide a 15- to 20-minute
lecture focused on healthy
eating habits, nutritional
guidance, or specific talks on
nutrition programming on
certain conditions such as
diabetes, hypertension, gout,
etc. StayWell provides free
healthy lunch to participants
of this activity, subject to
online HRA at our office during recommendation or suggestions approval by the governing
business hours. Our staff can assist for areas that need improvement agency.
them with registering online for the or are considered high risk. With b. Counseling, whether
EnjoyLife web portal. the approval of the member, a individual or as a group,
copy of member screening results through appointment with
and the follow-up letter are sent to one of our preferred providers
Worksite Health Screening the member’s primary care and wellness centers.
Worksite health screening may be physician or provider. An
c. Informational materials
arranged upon request by the aggregated report of the member’s
through the EnjoyLife web
employer/group and may be screening results is provided to
portal (online) or by request to
scheduled in advance for the policy their Human Resources
our office. To request a
year. During worksite health Department for the purpose of
lunch-and-learn or for more
screenings, members may receive offering specific recommendations
information on counseling, or
a number of screening tests, such to address the group’s health needs
our EnjoyLife web portal you
as Body Mass Index (BMI), blood and concerns.
may contact our office at (671)
pressure, and blood glucose tests,
477-5091 ext. 1185.
which are proven to be effective in
the early detection of certain Worksite Flu Vaccination Clinic
illnesses allowing for early Worksite flu vaccination clinics may Wellness Programs
intervention to make a real and be arranged upon request by the
StayWell members have access to
measurable impact. Members will employer group and may be
several health and wellness
also have the opportunity to scheduled in advance for the policy
programs through our Wellness
consult with a health coach and/or year. Together with their Wellness
Partners at Guam Seventh-day
nurse to discuss their screening Partners, StayWell will coordinate
Adventist Clinic (SDA) and Dr.
test results, address any questions each group to administer annual
Horinouchi Wellness Clinic.
or concerns the member might flu vaccines at no cost to eligible
have, and help the member plan members, all within the
the next steps to address the risks convenience of their worksite. SDA 7 Day Wellness Programs
or illnesses identified in their Influenza is a serious disease that The 7 Day Shape Up program is an
results. A "Health Screening can have fatal consequences with introductory program designed to
Record" is issued to members the "flu season" beginning as early help members implement healthy
which logs the tests measured as October and lasting as late as dietary intake and lifestyle habits.
during the screening. A follow-up May, in the U.S. The program addresses chronic
letter is sent to inform members of conditions including, but not
their screening results and any limited to diabetes, hyperlipidemia,
hypertension, obesity, etc. With the astounding. The powders provided support staff certified in smoking
Shape Up Program, members will for this program are compact with and tobacco smoking cessation
learn the importance of eating a nutrients from fresh fruits and strategy, and guiding participants
whole food diet and mindful vegetables to help the body’s to strengthen their motivation to
eating. The program also health on a cellular level. The 7 Day change. The program focuses on
emphasizes healthy eating habits, Advanced Detox program is not an physical effects and psychological
exercise regimens, sleep hygiene, all-liquid diet and participants will issues of smoking and utilizes
hydration level, management of be able to have unlimited fruits and natural solutions to help
blood sugar level for those with vegetables during the program. participants understand the effects
diabetes, as well as techniques to of tobacco use. Participants learn
improve determination/motivation The 7 Day Advanced Detox has skills and techniques to help them
to practice healthy lifestyle habits. helped participants improve their on their path to a smoke free
The program consists of a pre- and energy levels, lower the use of or lifestyle. The Stop-Smoking
post-screening, including BMI, eliminate maintenance program is covered at 100% of
weight, height, body fat medications, and improve their eligible charges. Members can
percentage, body water sleeping patterns. The program enroll in the program by calling the
percentage, muscle mass and also emphasizes healthy exercise Wellness Partners at SDA ((671)-
waist-to-hip ratio. At the regimens, sleep hygiene, and 648-2533) and Dr. Horinouchi
conclusion of the program, hydration levels. Wellness Clinic ((671)-646-9333).
participants can expect significant The NEWSTART Program is a
improvements in their weight, fat 2-week comprehensive course that
percentage, BMI, waist Dr. Horinouchi Wellness Clinic
has been meticulously designed,
circumference, cholesterol levels 2-Week Genesis Detox Program is
critically evaluated, and is
and blood pressure levels. health oriented, not disease
continuously improved to help
oriented. Members enrolled in the
The 7 Day Detox program is reverse chronic diseases, such as
program will have the opportunity
designed to cleanse the body by diabetes, high blood pressure,
to consult with the clinical
focusing on whole, unprocessed gout, obesity, chronic fatigue,
nutritionist for an individualized
foods that help nurture and heal hormonal imbalance, osteoporosis,
approach to identify and address
the body, while reducing toxins in food allergies, thyroid problems,
the member’s deficiencies and
the body. By emphasizing the arthritis, or inflammation. During
imbalances. The program includes
importance of exercise regimens, the program, participants will learn
a 2-week meal plan, 2-week
sleep hygiene, and hydration levels, about healthy lifestyle habits. The
supplementation to improve liver
the program can help with weight two-week long course emphasizes
function, detoxification and
loss, lowering, cholesterol levels, healthy exercise regimens, sleep
digestion health, weekly follow-up
and even reverse pre-diabetes. The hygiene, and hydration levels. The
assessments (blood sugar, blood
7 Day Detox program includes a NEWSTART program includes
pressure, weight and body
fresh fruit smoothies, whole food meals, cooking demonstrations,
composition), and an Ionic Detox
meals, and whole food powder group workout sessions,
Footbath. For more information or
mixes. Recipes and ingredients are discussions, and so much more.
to register for the program
provided for the weekend meals, The Stress Management program members can call the Wellness
which will be prepared by focuses on education and provides Partners at Dr. Horinouchi Wellness
participants. members with tools necessary to Clinic ((671)-646-9333).
The 7 Day Advanced Detox manage symptoms of stress and
Smoking Cessation counseling is
program is a continuation of the 7 daily stressors. Participants will be
available to all StayWell members
Day Detox program, and helps to focused on developing permanent
who are current smokers with a
address chronic conditions coping skills to reduce stress,
desire to make better lifestyle
including, but not limited to health related problems, and
choices by quitting smoking.
diabetes, hyperlipidemia, improve their overall lifestyle.
Smoking cessation counseling
hypertension, obesity, etc. The The Stop-Smoking program is sessions are patient-centered with
program includes high nutrient available to all StayWell members an individualized approach.
density whole food powder mix who are current smokers and wish Members will work with Dr.
with powder phytonutrients that to quit. The program is conducted Horinouchi to identify their
will help one to gain their health over five, two-hour sessions and deficiencies and imbalances, to
back, feel great, and look lead by a medical physician with address their individual needs, and
overcome their smoking habit. Stress & Emotional Health provides vital information to guide
Members can schedule their Management Class members in understanding their
individual smoking cessation Stress, whether physical, major health risks, and presents
counseling sessions by calling the emotional, environmental or useful advice on how to improve
Wellness Partners at Dr. Horinouchi mental, can impact the quality of their health and set achievable
Wellness Clinic ((671)-646-9333). our lives. Join Dr. Horinouchi and goals. The videos can be viewed at
discover the latest research on the member’s pace in the
Wellness Classes and Workshops nutrition and stress management convenience of their home, or it
with supplemental support. can also be a topic for discussion
Members are able to join Dr. in a Lunch-and-Learn activity. All
Horinouchi Wellness Clinic for free Addiction & Brain Health videos require an Adobe Flash
wellness and nutrition sessions. Management Class Player to view.
Topics will vary within each Addictions come in many different
workshop and may include forms, such as food cravings,
digestive health, detoxification and chemical dependency and even Wellness News and Health
heavy metals, hormone balance, some types of compulsive Educations Materials
childhood development, healthy behaviors. Sugar and junk food,
StayWell provides to our members
sleep, men’s and women’s health, nicotine and alcohol abuse can
monthly wellness and health
and much more. For more cause nutrition deficiencies and
education materials including:
information or to register for the trigger imbalance in hormones,
classes members can call the pain, anxiety and depression. High WellNotes™ is a monthly
Wellness Partners at Dr. Horinouchi potency supplements and a healthy newsletter that features current
Wellness Clinic ((671)-646-9333). diet can support overall wellness health topics and
without side effects. Join Dr. recommendations for living a
Cholesterol and Hormone Horinouchi and discover the latest healthy lifestyle. It is available
Deficiency Management Class research on nutrition and online through our website, or in
Today, cholesterol-lowering drugs addictions and brain health print through our office. Other
are the most commonly prescribed management with supplemental health education materials such as
medications in the United States. support. Monthly Health Challenge™ and
Cholesterol is the precursor or the Ask the Wellness Doctor™ are also
building block for the basic available to our members online, in
hormones: pregnenolone, DHEA, Online Wellness paper format, via electronic mail,
progesterone, estrogen, and at StayWell Health
StayWell members have access to
testosterone. Join Dr. Horinouchi Management events and activities.
several online tools to help them
and discover the latest research on
reach their health goals. Currently, Health Observances are a month-
nutrition and cholesterol
StayWell offers the following: to-month health awareness
management with supplemental
support. Online Health Activity Tracker, campaign to educate members
available through the EnjoyLife web about health risks and to provide
Metabolic Syndrome and Insulin portal, is an online tool that allows information on different health
Resistance Management Class members to stay on track with their topics. Communications are sent
Insulin, not cholesterol, is the true health activity. Each health practice out to members via electronic mail
culprit in heart disease. Metabolic or activity has a corresponding and advertisement of our
syndrome is the medical term for a point value that corresponds to participation in local and national
combination of diabetes, high their importance in leading a events like Guam Cancer Care,
blood pressure and obesity. It is healthier lifestyle, allowing Strides for the Cure, or Relay
also linked to a condition called members to properly appraise their for Life.
insulin resistance. Insulin is a health activities and reach their
hormone that helps the body health goals. The activities are Patient-Centered Education allows
control the level of sugar, or categorized into: key health StayWell’s health management
glucose in the blood. Metabolic practices, health events, health team to empower our members
syndrome increases the risk of challenges, self-study projects, and with the right information in
cardiovascular disease, diabetes, other wellness goals. becoming the most informed
stroke and coronary artery disease. health consumer. StayWell believes
Join Dr. Horinouchi to learn more The Healthy Living Guidelines™ that patients who are informed,
about how to control your insulin Streaming Video, is a 90-minute engaged, and equipped with the
level. online video divided into 12 brief tools to take care of their health
and educational chapters that utilize the healthcare system more
appropriately. Members may health plan for 12-months of • Screening for lipid profile
request for an electronic or printed continuous coverage within the disorders
copy of available health education reward period of the policy year. • Diabetes care (i.e.,
sheets, by contacting the Health Members must complete one or hemoglobin A1c, urine
Management Department by more of the following: microalbumin test, retinal eye
phone at (671) 477-5091 ext. 1185 • Annual completion of the exam, foot exam, fasting lipid
or by e-mailing enjoylife@ online HRA profile)
staywellguam.com.
• Preventive health services • Completion of dental
for age and gender, as prophylaxis/cleaning services
EnjoyLife Rewards Program recommended by the United • Completion of two StayWell-
States Preventive Services Task approved health education
The EnjoyLife Rewards Program is
Force (USPSTF) guidelines: classes
offered to certain group health
plans as an added benefit. This • Annual physical exam • Participation in monthly gym/
wellness incentive program aims to • Screening mammogram fitness activities
inspire members to adopt healthy and clinical breast exam
behaviors and take proactive steps for breast cancer
in maintaining and improving their
• Cervical cancer screening
health. Eligible members must be
with Pap Smear
at least 18 years or older at the start
of their policy year with the • Colorectal cancer
EnjoyLife Reward Program under screening
their health plan, enrolled in the • Osteoporosis screening
Community Resources
StayWell members are provided information on resources, treatment options and local community–based
programs that are focused on alcohol and substance abuse and violence prevention.
24 Hour Hotline Emergency Contact Numbers
Guam Alternative In case of an emergency please call 911

Lifestyles Association Dededo Precinct
Phone: (671) 969-5483
(GALA) 24-hour Crisis Phone: (671) 632-9809 /
Helpline (671) 632-9811
Tumon/Tamuning Precinct
Guam Crisis Helpline Phone: (671) 647-8833
Phone: (671) 649-6330 /
National Suicide Guam Police (671) 647-9660
Phone: 1 (800)–273-TALK (8255)
Prevention Lifeline Department Agat Precinct
Community Organizations Phone: (671) 472-8915 /
250 Route 4 Suite 204 Nanbo (671) 472-8916
American Cancer Guahan Bldg. Hagåtña, GU Central Precinct
Society 96913 Phone: (671) 475-8537 /
Phone: (671) 477-9451 (671) 475-8541
234A US Army Juan G. Fejer- Emergency Departments
an Street Barrigada, GU 96913
Guam Memorial Ward Clerk: (671) 648-7909 /
Catholic Social Services Phone: (671) 635-1442
Hospital Authority 7910
www.catholicsocialserviceguam.
(GMHA) GMHA Operator: (671) 647-2555
org
Guam Regional Medical
341 S. Marine Corps Drive RK Phone: (671) 645-5500
City (GRMC)
Plaza Suite 102 Tamuning, GU
Guam Cancer Care Family Care Giver Support Services
96913
https://www.guamgetcare.org/
Phone: (671) 969-3222
Get Care consumer/explore/caregiver_
220 T. Stanaka Bldg. Suite 100, 4
Guam Diabetes resources/
Hagåtña, GU 96913
Association 809 Chalan Pasaheru Unit 2,
Phone: (671) 671-477-7776
Tamuning, GU 96913
194 Hernan Cortez Avenue Health Services of
Phone: (671) 735-3277
Hagåtña, GU 96910 the Pacific – National
Fax: (671) 734-6477
Phone: (671) 735-7265 Family Caregiver
https://www.hspguam.com/
Guam Diabetes Control Fax: (671) 735-7500 Support Program
national-family-caregiver-
Coalition c/o: Guam Diabetes Prevention
support-program
and Control Program (DPHSS)
Guam Behavioral Health and Wellness Center
https://m.facebook.com/
790 Governor Carlos G. Camacho Rd. Tamuning, GU 96913
guamdiabetescoalition/
https://gbhwc.guam.gov
Corten Torres Street Mangilao,
Child/Adolescent J&G Commercial Bldg. Chalan
GU 96913
The Salvation Army Services Department Santo Papa St. Suite 107F
Phone: (671) 472-7671
Guam Corps (I’ Famugu-on’ Ta) Hagåtña, Guam
https://hawaii.salvationarmy.org/
hawaii/guam Clinical Services
Phone: (671) 647-5440
Department
Counseling Services
J&G Commercial Bldg. Chalan
Inafa’maolek Inc. Phone: (671) 475-1977
Drug and Alcohol Santo Papa St. Suite 105F
Peer Mediation and Email: inafamaolek@teleguam.
Treatment Branch (New Hagåtña, Guam
Conflict Resolution net
Beginnings) Phone: (671) 475-5438/40
Office Hours: Monday-Friday
Fax: (671) 477-7782
9:00AM-8:00PM
Isa Psychological Phone: (671) 477-9079 thru
Phone: (671) 735-2883 Prevention and Training
Services Center 9083
Email: isa@triton.uog.edu Branch (PEACE)
Fax: (671) 477-9076
www.uog.edu
Rape Crisis Center -
Phone: (671) 647-5351
Healing Hearts
Guam Department of Public Health and Social Services (DPHSS) Sexual Assault Services 24-Hour Access
http://dphss.guam.gov/ Alee Shelter Crisis
Support for family
Bureau of Phone: (671) 648-4673
violence and sexual
Communicable Disease
assault
Control
Victim Advocates
Immunization Program, Phone: (671) 477-5552
http://dphss.guam.gov/bureau- Reaching Out (VARO)
STD/HIV Prevention
of-communicable-disease- Substance Abuse Services
Program, Ryan White
control/
HIV/AIDS Program, Family Services Center Phone: (671) 477-3528/9
Tuberculosis/Hansen’s
Oasis Empowerment
Disease Control Phone: (671) 646-4601
Center
Program
Salvation Army
Community Health Phone: (671) 477-7671
LIFEHOUSE Recovery
Services Section (CHSS) Fax: (671) 477-4649
Center for Men
Guam Diabetes
Tobacco Use Services
Prevention and
Tobacco Prevention
Control Program, Phone: (671) 735-7303
and Control Program
Tobacco Prevention Quit Line: 1-800-QUIT-NOW
- Guam Department of
and Control Program (1-800-784-8669)
Public Health and Social
and the Tobacco www.quitnow.net/guam
Services (DPHSS)
Quitline, Sexual
http://dphss.guam.gov/dph/ Youth-Serving Programs
Violence and Prevention
Program, Breast and communityhealthservices/ Island Girl Power
Cervical Cancer Early Positive activities for Phone: (671) 989-1602/3/4
Detection Program, young girls and their (671) 688-4752
Comprehensive Cancer families
Control Program, Sanctuary, Inc.
Behavioral Risk Factor Outreach Crisis
Phone: (671) 475-7100
Surveillance System Intervention
(BRFSS), and The Non- for Youth
Communicable Disease Youth for Your Live!
Control Program Guam Phone: (671) 487-0523
Division of Senior Youth helping youth Email: yfyliveguam@gmail.com
Citizens through empowerment www.yfyliveguam.org
and leadership
Adult Protective
Services, Congregate
Meals, Home-Delivered
Meals, In-Home
Services, Transportation https://dphss.guam.gov/
Services for Medical and division-of-senior-citizens-2/
Hemodialysis, Guam
Medicare Assistance
Program (MAP) and
State Health Insurance
Assistance Program
(SHIP)
FITNESS StayWell’s Fitness Class Calendar is education of these members and
The Physical Activity Guidelines for updated monthly and can be found emphasize the importance of
Americans recommends two types online on our website, or in print at proper self-management of their
of health-enhancing physical our office. Please call our Health disease and regular care. It also
activity: aerobic (cardiovascular) Management Department at (671) aims to provide support tools and
and muscle-strengthening. For 477-5091 ext. 1185 or email at resources to reduce diabetes-
significant health benefits, adults enjoylife@staywellguam.com to related complications and
(age 18–64) should do any obtain a copy of this month’s morbidities. The components of
equivalent mix of moderate and fitness schedule. the program include: condition
vigorous intensity aerobic activity monitoring and reporting, patient
AND muscle-strengthening adherence, consideration of other
CHRONIC DISEASE health conditions and lifestyle
activities on 2 or more days a week
that work all major muscle groups. MANAGEMENT issues, intervention strategies and
To meet the recommended StayWell’s Medical Care access to Diabetes Self-
physical activity guidelines, Management Department, through Management Training (DSMT). To
StayWell has partnered with the its Utilization Management– ensure and improve program
following fitness centers to offer Informed Choice (UM–IC) efficacy, outcomes are measured
fitness classes to all StayWell department, provides a variety of and assessed through a
members (both subscribers and programs that oversees the collaboration of program staff and
dependents) at no charge: different populations with specific partners.
• International Sports Center, conditions, whether acute or
located in Hagåtña next to chronic. The DiaBEAT-It! Living Well with
KFC Diabetes Program is the only
• The Pound Academy, located StayWell’s Disease Management program accredited by the
in Dededo and offering Program for Coronary Artery Diabetes Education Accreditation
classes at Hyatt Regency Disease (CAD) is designed to Program, AADE on Guam. It is a
Guam identify members with CAD. 2-week program that consists of
Following the American College of tools to live well with diabetes,
• Urban Dance Studio, located Cardiology and the American Heart such as diabetes reversal/
in Maite Association Practice Guidelines, the remission, health eating/health
To register for these classes, program will assist in educating coping with follow ups up to 12
members are required to fill out a members about CAD by months, and much more via the 7
one-time registration form and emphasizing the importance of Day Program. A booklet and
provide a copy of their health proper self-management of their program information will be given
insurance card with a valid picture chronic condition and regular care. to each participant. The program
ID on their first visit to the fitness The components of the program consists of a pre- and post-
facility of their choosing. include: condition monitoring and screenings including lab work.
Members are able to enjoy a wide reporting, patient adherence, The American Medical Center
variety of exercise classes that consideration of other health Diabetes Education Program
provide different levels of health- conditions and lifestyle issues, and provides Diabetes Self-
enhancing physical activity, with an intervention strategies. The Management Education in a
equivalent mix of light, moderate, components of the program one-on-one setting with schedules
or vigorous intensity moves. include: condition monitoring and based on the individual’s
Whether you opt for cardiovascular reporting, and intervention preferences, meeting 12 sessions a
(aerobic) training, muscle- strategies. To ensure and improve year. The Diabetes Education
strengthening, or flexibility and program efficacy, outcomes are Program provides an introduction
resistance training, these classes measured and assessed through a to the American Association for the
are facilitated by certified collaboration of program staff and Diabetes Educators 7 self-care
instructors that will surely help you partners. behaviors and works with clients to
improve your health. Certified develop SMART goals. Regular
fitness trainers are also available to StayWell’s Disease Management education sessions include disease
provide assistance to individuals Program for Diabetes is designed process, nutrition, exercise, blood
with physical and mental to identify members with type 1, glucose monitoring, medication,
impairments. type 2, and gestational diabetes. preventing/delaying complications,
The program will assist in complication management,
reducing risks, behavioral and in the CNMI is the only diabetes Our case managers use a team
lifestyle change and healthy program to be certified by the approach to ensure an effective
coping. People with diabetes have American Diabetes Association in discharge planning and care
specific and individual needs and any of the United States Pacific coordination for all our members,
no two clients are alike. Individual Territories. The 12-month program particularly those with chronic
education sessions will allow for covers seven modules which conditions (i.e., CAD, diabetes with
client’s specific concerns and discuss topics on healthy eating, complications) and catastrophic
needs to be addressed while being active, blood glucose illness identified by self-referrals or
maintaining confidentiality and monitoring, taking medications, by referral from their primary care
privacy of the client and their acute complications, healthy provider. By a team approach, we
information. The client’s family and coping, and long-term involve the attending physician,
any support members are complications. The program does primary care provider if different
encouraged to attend all education not end after the seven modules from admitting physician, hospital
visits and to be involved in the are introduced. Doctors and staff, social worker, home health
client’s care. Clients will be called educators will work with the care agency, and pharmacy in
by staff members at American patient to discuss and develop their addressing potential gaps in the
Medical Center 2 to 3 days prior to Diabetes Self-Management systems of care. StayWell UM-IC
the client’s appointment to remind Support strategies during the 10 staff facilitate appropriate and
them of their scheduled visits. hours of DSME service to ensure efficient delivery of health care
certain sustainability of lifestyle services to these members to
modifications made during the better manage their overall health.
The Diabetes Self-Management program. There will be three-hour
Education Program at Hardt Eye post program follow-up each
Clinic & Diabetes Education Center calendar year afterwards.
COSTS and CLAIMS
ELIGIBLE CHARGES The Eligible Charge for Services by When an off island dental provider,
Services at a Participating Provider a Non-Participating Provider will be outside of the United States treats
are based on Eligible Charges. less than for a Participating you, you must request the provider
Provider. You are responsible for to complete an Off Island Dental
When you receive service from a paying the specified Coinsurance/ Claim form and submit the
Participating Provider for Copayment plus any amount by completed form with an original
treatment, that provider will submit which the Provider’s charge receipt for reimbursement. You
your claim to StayWell Insurance. exceeds the Eligible Charge. may obtain the form at the
Payment will be made directly less StayWell office or at staywellguam.
any amounts that you are com.
responsible for (e.g., applicable HOW TO MAKE A MEDICAL
coinsurance/copayments, CLAIM
expenses above StayWell Insurance
Eligible Charges, etc.). Covered When a Participating Provider
services will be paid provided the treats you, that Provider will submit
Provider of services bills StayWell your claim to our office, unless the
within ninety (90) days after the Provider agrees to file the claim on
date in which the service was your behalf. However, if you should
rendered. receive treatment from a non-
Participating Provider you must pay
If you receive services from a for the services and then seek
Non-Participating Provider, reimbursement from StayWell,
StayWell will pay only a percentage unless the provider agrees to file
of Eligible Charges (see Summary claim on your behalf. Request your
of Coverage for details). The reimbursement by sending to
Company has no agreement with StayWell Insurance your itemized
Non-Participating Providers and bill and original receipt within
they may charge you more than ninety (90) days after the date in
the Eligible Charge for any Service. which the service was rendered.
For reimbursement of eligible • Diagnosis code (ICD10) • Name of prescribing

expenses that you’ve paid in • Procedure code (CPT) physician
full, please submit the following • Name of procedure • Date of Service
documents: • Itemized billed charges • Name and strength of
• Proof of payment medication
DOCTOR’S SERVICES • National Drug Code (NDC)
• Name of Doctor HOSPITAL SERVICES • Quantity
• Date of Service • Proof of payment in full • Itemized billed charges
• Diagnosis code (ICD10) • UB-04 claim form • Proof of payment
• Procedure code (CPT) • Itemized breakdown of total
• CMS 1500 claim form charges
• Itemized billed charges If you submit a bill in a
• Complete medical report foreign language for services
• Proof of payment • Patient account number rendered off island, all required
• Proof of payment information must be translated
LABORATORY
into English for you to receive
• Name of Laboratory PRESCRIPTION DRUGS reimbursement.
• Name of referring physician • Name of Pharmacy
• Date of Service
COORDINATION of BENEFITS
DUAL COVERAGE you may qualify for premium- Those who wish to enroll in a
If you’re covered under any other free Part A insurance. Otherwise, Medicare Part D program must
health plan this is called “dual you may become eligible upon choose from a large list of
coverage”. As a StayWell member reaching age 65 or older. approved drug plans.
you are responsible for informing • Part B (Medical Insurance): Should you become eligible, you
StayWell of your dual coverage as Generally, Medicare Part B acts must enroll in Medicare to ensure
soon as, or prior to, the start date like most other health plans, and no interruption in your coverage as
of each “Other Plan”. The benefits premiums are withheld from your StayWell plan benefits will be
and health plan for Members with your monthly Social Security reduced by the amount that is
dual coverage will be appropriately check or your monthly covered by Medicare, even if you
coordinated and adjusted so that retirement check. are not currently enrolled.
benefits will not exceed 100% of • Part C (“Medicare+Choice” now For more information on Medicare
allowable charges between your known as “Medicare you may contact the Guam
StayWell plan and each Other Plan. Advantage”): Through the 1997 Medicare Assistance Program
Should StayWell be determined to Balanced Budget Act Medicare under the Department of Public
be your primary health plan, then Part C offers Medicare benefits Health and Social Services at
the benefits described in your to include medical savings 671-735-7388 or Medicare directly
StayWell health plan will apply to all accounts, managed care plans, at 1-800-633-4227.
eligible charges. When StayWell is and private fee-for-service
the secondary health plan, then plans. The new Medicare Part C
StayWell will determine its benefits programs are in addition to the
contributions based on the allowed fee-for-service options available
amount not paid by your primary under Medicare Parts A and B.
health plan. In addition, note that • Part D (Prescription Drug
additional provisions apply for Coverage): Medicare offers a
those who are eligible for prescription drug benefit within
Medicare. which you may enroll only if you
For more information regarding are enrolled in Part A or Part B.
dual coverage under your StayWell
health plan please contact our
customer care department at
671-477-5091.
MEDICARE
Medicare is a U.S. health insurance
program for:
• People 65 years of age or older.
• Some people with disabilities
under age 65 years of age.
• People with End-Stage Renal
Disease (permanent kidney
failure requiring dialysis or a
transplant).
Medicare has four parts:
• Part A (Hospital Insurance): If
you or your spouse have worked
for at least 10 years in U.S.
Medicare covered employment,
DENTAL CARE
You have the option of enrolling Pre-authorization by StayWell is
in our dental plan. Once you join required for treatment estimated to
you must continue receiving cost $600 or more.
dental coverage to the end of Staying within the StayWell
the policy year. Cancellation of network of participating dentists
dental coverage can only be will ultimately save you money!
done during the annual open Your coinsurance will substantially
enrollment period. Most dentists increase when Services are
send the bill for your care rendered by a non-participating
directly to StayWell for payment dentist.
of Eligible Charges on covered
Services, less the part you pay as
your Coinsurance. Some
dentists, however, prefer to have
their patients pay them directly.
If this is your dentist’s procedure,
you pay 100% of the bill and
then submit a claim to StayWell
for reimbursement. We require a
copy of your dentist’s bill, listing
all the Services performed and
the price for each Service.
GENERAL
INFORMATION
CUSTOMER CARE The StayWell Customer Care ELIGIBILITY INFORMATION
Customer Care Representatives are Department is there to provide Who is Eligible?
trained in your plan’s coverage, quick answers to your questions
benefits and procedures. They can regarding: Subscriber:
provide you with up-to-date lists of • Claims • Resident of Guam or CNMI
StayWell’s Participating Providers • Providers • Regular full-time employee
and Centers of Excellence – the who works 30 hours or more
doctors, hospitals, clinics, • Eligibility
per week
laboratories, pharmacies and other • New Cards
health care providers, which offer Dependent:
• Memberships
services at reduced rates to • Resident of Guam or CNMI
StayWell members. They can also
• Reimbursements
• Legal spouse or domestic
help you file claims and receive Call Guam Customer Care at partner. Domestic partner
reimbursements, which include (671) 477-5091 extension 1120, or must be at least 18 years old
cases where you paid 100% for a CNMI Customer Care at (670) and has lived with you for
covered Benefit on Guam or off 323-4260, or stop by the StayWell at least two (2) consecutive
island. Guam/CNMI Office. We’re open years. Domestic partner
Monday–Friday from may only be enrolled during
8:00 a.m. to 5:00 p.m. open enrollment or initial
enrollment.
• Natural children, stepchildren, you must complete a "change What else is required?
legally adopted children, of status" form signed by you • Marriage certificate copy if
children placed for adoption as the subscriber and submit the spouse has a different
under the age of 26. Children to StayWell within 30 days of last name or enrollling due to
of domestic partners are not the eligibility. marriage.
eligible for coverage as a
stepchild. • Birth certificate copy if a child
When to Enroll has a different last name.
• A child of a domestic partner
can enroll as a dependent • Within 30 days of the time you • Domestic partner. StayWell
if the domestic partner is are first hired; shall require a notarized
enrolled as a dependent • Within 30 days of the time you affidavit and other proof of
of the same subscriber. If first become eligible for the domestic partner status at
the domestic partner is not plan. the time of application for
enrolled, then the subscriber enrollment. The Subscriber‘s
• During the annual enrollment domestic partner is eligible
must have legal guardianship period; or
of the domestic partner’s if (i) both the Subscriber
child to enroll said child • Within 30 days after a HIPAA and the domestic partner
as a dependent. A child of event. Please refer to "HIPAA are eligible for marriage
a domestic partner may Provisions" section below for without emancipation under
only be enrolled during further explanation. the laws of Guam/CNMI
open enrollment or initial • Within 30 days of birth, (ii) the domestic partner
enrollment. adoption, marriage, or has cohabited with the
placement for adoption. Subscriber for at least the
• Legal guardianship. Children last two (2) consecutive years
under legal guardianship Once you join you must continue
immediately preceding the
may only be enrolled during receiving medical coverage to the
proposed date of enrollment
open enrollment or initial end of the policy year. Cancellation
of such spouse.
enrollment. A child under of medical coverage can only be
legal guardianship will remain done during the annual open • Legal guardianship. The
eligible until guardianship enrollment period. subscriber shall provide
terminates, or until the such evidence as to
child reaches the age of 18 the qualifications of the
years, whichever occurs HIPAA Provisions dependent for legal
earlier. An unborn child As required by the Health Insurance guardianship as StayWell may
cannot be enrolled under Portability and Accountability Act require, including but not
legal guardianship. Legal (HIPAA) of 1996, if you decline to limited to annual tax filings
Guardianship is not a HIPAA enroll yourself or your dependents and affidavit stating that the
qualifying event. (including your spouse) in StayWell dependent will be included
because of other health insurance in the tax filing and court
• Children age 19 through 25. document copy signed by a
If the child resides outside coverage, you have the option to
enroll later, if there is a qualifying judge ordering guardianship.
of Guam and the CNMI and
is attending an accredited event and provided you submit all • Stepchildren. A copy of the
school, college, or university enrollment application forms child’s birth certificate and the
as a full-time student, a full within 30 days of losing the other parents’ marriage certificate.
time school verification must coverage. You also have the option • Adoption. Court document
be submitted. to enroll again in StayWell when copy signed by a judge
you have a new dependent as a ordering adoption or
• Disabled child incapable of
result of marriage, birth, adoption placement for adoption.
self-sustaining employment
or placement for adoption,
by reason of mental • Students (age 19-25) that
provided you enroll within 30 days
retardation or physical reside outside of Guam and
of acquiring the new dependent.
handicap. A medical CNMI. Letter from school’s
Only under these events will you
certification from your doctor registrar’s office verifying
be allowed enrollment.
must be submitted. full-time status. Verification
• To add eligible dependents, must be submitted no
including newborn babies, later than 30 days after the
commencement of each
term.
• Disabled child. Proof of total Eligible Charge and actual costs. provides for medical payments.
disability and dependence You are responsible for paying StayWell will cover whatever is
must be submitted within 30 all health care Services not not paid by your auto policy
days of the child’s attainment covered by StayWell. subject to policy conditions and
of the limiting age and every limits.
year after that. 2. Double coverage: If you are
covered by a group medical If there was more than one car
• Newborn. Copy of birth plan, Medicare, or automobile involved and the accident was your
certificate showing subscriber insurance in addition to fault, then StayWell will pay per
as parent. StayWell, one plan will pay policy conditions and limits
StayWell reserves the right to reduced Benefits. This is to whatever is not the responsibility of
require a Covered Person or prevent any payment of Benefits your auto policy.
Employer to provide documentary exceeding the charge for a If there was more than one car
evidence of eligibility of Covered particular service. Benefits will involved and the other party is at
Person to supplement an be adjusted so you do not fault, then the driver of the other
application for enrollment or to receive more than 100% of the car and that other car’s auto
confirm eligibility. Other Eligible Charges. Medical insurance policy must pay all of
documents may be required to coverage under Medicare will be your medical expenses. StayWell
determine whether they are considered primary for payment will not pay anything when the
acceptable substitutes, however, unless otherwise provided for by other person is responsible.
final determination will be made by federal law. Motor vehicle However, StayWell may make
StayWell’s Enrollment Department. insurance will be considered payments on your medical
primary for all medical care expenses in the form of a no
resulting from a motor vehicle interest loan pending the outcome
Residency Requirement accident. Those Benefits will be of your action against the other
StayWell members must maintain applied first before StayWell pays party. In order to have StayWell
their principal residence in Guam any Benefits. make such payments, you must
or the CNMI. Employees/members In the case of a dependent child, apply for this special benefit.
cannot remain outside the Service the carrier of the parent whose
Area for more than 60 birthday occurs first in the
accumulative days per policy year. Non-Member Status
calendar year is the primary
A written request for extension may carrier. Members are at risk of losing their
be submitted to StayWell’s coverage with StayWell if any of
If you receive care at military the following circumstances occur:
Informed Choice Department prior
medical facilities, the Third Party
to the 60th day. The granting of a) If premiums are not paid.
Collection Program established
any extension shall be at the sole
by federal law PL99-2782 (10 b) If you allow someone else to use
discretion of StayWell, is not
USC1095) directs the military to your membership card to obtain
automatic and is subject to review
bill private insurance companies Services.
after submission of all documents
for the cost of care provided by c) If you remain outside the Service
as determined necessary by
the military facility. Area for more than 60
StayWell.
3. Third party liability: If another accumulative days, off island
Dependents age 19-25, who are
person causes your injury and benefits will be terminated.
full-time students as described in
you have a right to recover d) A spouse’s coverage will end on
your group contract, will not be
damages from that person, the first day of the month
excluded from coverage while
StayWell is not liable for benefits following the termination of
attending school outside the
in connection with services your marriage. A domestic
Service Area provided proof of
rendered. Should StayWell elect spouse’s coverage will end on
full-time student status must be
to make payments for your the first day of the month
submitted each semester.
injury, it has the right to be following the date the couple is
reimbursed from any recovery no longer living together. You
Exceptions you obtain from the third party. must complete and submit all
1. Exception for difference: You 4. Auto accidents: If yours is the necessary forms in these events.
must pay for any difference only car involved and you are e) When eligible for Medicare
between StayWell’s payment on injured, the primary coverage coverage and you fail to enroll in
will be your auto policy if it
all portions of the Medicare
Program open to you and refuse
to sign or maintain in effect the
necessary releases. This includes
members eligible for Medicare
due to end stage renal disease.
f) If a medical claim for
reimbursement is found to be
fraudulent after all required
grievance actions have been
completed.
REVIEW AND APPEALS

PROCESS
If you have questions about the
benefit coverage or payments
made by StayWell, you are entitled
to request a review of the claim. If
you are not satisfied with any
preliminary determination made,
you or your authorized
representative are entitled to
appeal in writing to StayWell’s
Appeals Committee.
If an authorized representative is
filing the appeal on your behalf,
you will need to complete the
StayWell Authorized Representative
form to name the representative.
Your doctor can only obtain the
right to act on your behalf in • Explain why you believe the B. The Appeals Committee has
pursuing appeals if your doctor has initial determination should thirty (30) days from the date it
become your authorized be reconsidered, based on received your Pre-Service Appeal
representative. In the case of an the benefit provisions in your and sixty (60) days from the date it
appeal involving urgent care, the health plan; and received your Post-Service Appeal
provider treating you can to:
automatically act as your • Attach documents supporting
authorized representative without your explanation including • Authorize coverage for the
your having to complete the medical records, physician requested service, or supply;
StayWell Authorized Representative letters, bills, receipts and any • Request for more information
form. other form that would serve from you or your provider –
the same purpose. Proceed to Step C; or
How do I file an appeal?
• File for an expedited internal • Write to inform you that
A. Appeal to StayWell in writing to appeal in urgent care
reconsider initial decision. You the denial is maintained –
situations by contacting our Proceed to Step D
should: Customer Care Department
• Write to StayWell’s Appeals at (671) 477-5091 ext. 1120. C. You or your provider should
Committee within six (6) Urgent internal appeals will send the information so that the
months from the date be processed within 24 to 72 Appeals Committee will receive it
of StayWell’s decision or hours. You may request for within forty-five (45) days of our
Accomplish StayWell’s Appeal an expedited internal appeal request. The Appeals Committee
Form; and orally or in writing. will then decide within thirty (30)
• Send your appeal to StayWell more days.
at: 520 Route 8 Maite, Guam
If information is not received within
96910; and
forty-five (45) days, the Appeals You may submit additional written The examiner, designated by
Committee will decide within thirty comments to the external reviewer, MAXIMUS, must provide notice of
(30) days from the date the though any submitted information the expedited external review
information was due. The decision will be shared with us to give decision as promptly as your
will be based on available StayWell an opportunity to medical conditions or
information. The Appeals reconsider the denial. If you have circumstances require, but no
Committee will write to you about any questions or concerns during more than 72 hours after receipt of
the decision. the external review process, you the request for an expedited
can call MAXIMUS at the toll-free external review.
D. If you do not agree with the number 1-888-866-6205 or The examiner will provide you and
Appeals Committee’s decision, you contact the Guam Department of StayWell with an oral or written
can file an External Review. Revenue and Taxation, Regulatory decision. Any decision provided
Proceed to Step E; Division at (671) 635-1844/5 or orally by the examiner will be
(671) 635-7664. followed by a written notice within
E. Almost always, issues find 48 hours.
resolution within the first level of When the examiner, designated by
If you do not agree with the final
appeal. Otherwise, you may seek MAXIMUS, receives an external
determination on your internal or
arbitration or request for standard review request, the examiner will
external appeal, you have a right to
or expedited external review. contact StayWell. Within five (5)
bring a civil action under Section
business days of receipt of request
by the examiner, StayWell will 502(a) of ERISA, if applicable.
For more information regarding provide to the examiner all of the
this, you may contact StayWell’s documents and any information COMPLAINTS AND
Customer Care Department at considered in making the Adverse
GRIEVANCES
(671) 477-5091 ext. 1120. Benefit Determination or final
internal appeal decision We have steps for handling any
F. Standard external review. problems you may have. As a
Within forty-five (45) days after StayWell member, you have a right
If we continue to deny the
receipt of the request for external to voice your complaint if you are
payment, coverage, or service
review, the examiner will provide not happy with our providers or
requested or we do not comply
you and StayWell a written with us. To make a complaint,
with Federal Standards, or in the
decision. If the decision of the please call Customer Care or come
case of medical urgency, you may
examiner includes reversal of the into our office to speak with one of
be able to request an external
denial of coverage or service, our Customer Care staff. Some
review of your claim by an
StayWell will immediately comply. complaints can be resolved
independent third party, who will
through first call resolution if they
review the denial and issue a final
G. Expedited external review. can be fully addressed and you are
decision.
satisfied with the outcome.
Per the interim external review In urgent care situations, e.g. when
the expedited/urgent internal If your complaint cannot be
guidelines issued by Health and
appeals process timeframe would resolved or it meets the definition
Human Services (HHS), this process
seriously jeopardize your life and of a grievance, you can complete
will be administered by MAXIMUS
health or would jeopardize your the Grievance Form and submit it
Federal Services. Within four (4)
ability to regain maximum function, to StayWell. We will send you a
months after receipt of a denial of
you may request for an expedited Grievance Acknowledgment letter
coverage or service, request for an
external review by selecting after receipt of your written
external review in writing by
“expedited” if submitting the review grievance. All grievances will go
submitting an online request at
request online, or by emailing under review by the appropriate
externalappeal.cms.gov, under the
FERP@MAXIMUS.com, or calling department and the Quality
“Request a Review Online” heading,
Federal External Review Process at Assurance Manager. We will inform
or in writing by faxing the request
1-888-866-6205 ext. 3326. If you you in writing within 30 days as to
to 1-888-866-6190, or by sending
have an urgent health situation, how your grievance was addressed.
it by mail to: MAXIMUS Federal
you can file for an external appeal, If additional time is needed for
Services, 3750 Monroe Avenue,
orally or in writing, at the same resolution, we will keep you
Suite 705, Pittsford, NY 14534
time as your request for an internal informed, in writing, on the status
appeal. of your grievance until it is
resolved. If you require assistance
in filing a grievance or if you are The Quality Improvement
unable to submit the grievance in Committee (QIC) is a StayWell
writing, you can call Customer committee with physician
Care at 671-477-5091 to ask for representation that is directly
help through the process. accountable to the BOD. The
purpose of the QIC is to prove
oversight and direction in assessing
QUALITY IMPROVEMENT the appropriateness of services and
PROGRAM continuously enhance and improve
StayWell has a comprehensive the quality of care and services
Quality Improvement (QI) Program provided to members. This is
to ensure members receive quality accomplished through a
care and services. The QI Program comprehensive, plan-wide system
is an important part of the of ongoing, objective, and
member’s health plan. The StayWell systematic monitoring; the
Board of Directors (BOD) oversees identification, evaluation, and
the QI Program and has established resolution of process problems;
various committees to monitor and the identification of opportunities
support the QI Program. The BOD to improve member outcomes;
has the ultimate authority and and the education of members,
accountability for the oversight of providers, and staff.
the quality of care and service Another aspect of our quality
provided to members. The QI program and the services we
Program monitors the quality of provide to our members is the
care and services provided in some member satisfaction survey. The
of the areas below: survey is conducted by an external
• Making sure members get vendor on an annual basis. The
the care they need, when and survey provides information on the
where they need it experiences of members with
StayWell’s services and the provider
• Making sure members are
services. The survey gives us a
receiving quality care
general indication of how well we
• Cultural and linguistic needs are meeting the needs of our
of our members members. We also evaluate
• Member satisfaction member complaints, grievances,
appeals, and denials annually. We
• Member safety and privacy
encourage all members to
• Network access and adequacy participate in the survey so we can
The goal of the QI Program is to enhance our quality improvement
improve member health. This is initiatives.
achieved through many different If you would like more information
activities. Some of our goals about our QI Program, contact the
include the following: Quality Assurance Manager at
• Provide timely access to 671-477-5091 ext. 1231
high-quality healthcare for
all members, through a safe
health care delivery system;
• Systematically monitor and
evaluate the quality and
appropriateness of health care
and services; and
• Pursue opportunities to
improve health care, services,
and safety.
GLOSSARY
ADVERSE DETERMINATION means: CENTERS OF EXCELLENCE The selected off island
hospitals and ambulatory surgi-centers that have
1. A determination by StayWell that is based upon the agreed to provide health care services at reduced rates
information provided, a request for a benefit under to StayWell members.
StayWell’s health benefit plan upon application of
any utilization review technique that does not meet COVERED SERVICES The medical and dental services
StayWell’s requirements for medical necessity, for which you are insured under this plan.
appropriateness, health care setting, level of care
or effectiveness, or is determined to be COINSURANCE The portion of charges for Covered
experimental or investigational and the requested Services for which an enrollee is responsible for
benefit is therefore denied, reduced, or terminated, payment after satisfaction of the Deductible.
or payment is not provided or made, in whole or in COMPLAINT Any verbal expression of dissatisfaction
part, for the benefit; The denial, reduction, by a Member or a Member’s Authorized Representative
termination or failure to provide or make payment, regarding an issue that may be resolved at the point at
in whole or in part, for a benefit based on a which it occurs by the staff present. Most complaints
determination by IHIC of a member’s eligibility to will have simple solutions that can be promptly
participate in the health plan; or Any prospective addressed and are considered resolved when the
review or retrospective review determination that member/authorized representative is satisfied with the
denies, reduces, or terminates or fails to provide or action taken on their behalf.
make payment, in whole or in part, for a benefit.
COPAYMENT The predetermined (flat) dollar amount
2. Adverse Determination also includes a rescission of that an enrollee must pay for certain Covered Services
coverage determination. after satisfaction of the Deductible.
APPEAL An appeal is a request by the Member or the DEDUCTIBLE A deductible is the amount required to
Member’s Authorized Representative for be paid by you for Covered Services rendered before
reconsideration of an Adverse Determination of a the plan participates in paying your Covered Services
health service request or benefit that the Member rendered.
believes he or she is entitled to receive.
DOCTOR A properly licensed doctor of medicine
1. Urgent Care Appeal – Also known as an Expedited
(M.D.), psychiatrist, licensed clinical psychologist,
Appeal, are a special kind of pre-service appeal that
dentist(D.M.D. or D.D.S.), doctor of osteopathy (D.O.),
requires a quicker decision when there is an
or doctor of podiatric medicine (D.P.M.)
immediate need for health services because a
standard appeal could jeopardize the member’s ELIGIBLE CHARGES Shall be defined as the portion of
life, health, or ability to attain, maintain, or regain charges made to a Covered Person for Covered
maximum function. If a physician with knowledge Services rendered which are payable to the Provider.
of the members medical condition tells StayWell For Covered Services rendered by a Participating
that a pre-service appeal is urgent, StayWell must Provider, the Eligible Charges shall be limited to the
treat it as an urgent care appeal lesser of the actual billed charges or the
reimbursement amounts agreed to between the
2. Pre-Service Appeal (Prior Authorizations) – Are
Company and the Participating Provider. For covered
requests for reconsideration of an Adverse
medical Services rendered by a Non-Participating
Determination for approval required before
Provider, the Eligible Charges shall be limited to the
medical care, such as preauthorization or a
lesser of the actual billed charges made by the
decision on whether a treatment or procedure is
provider; or in the United States, the Medicare
medically necessary.
Participating Provider fees in the geographic area
3. Post Service Appeal – Are all other Appeals for where the Service was rendered; or in Asia, the fees
benefits under IHIC’s health plan that are not most recently contracted by the Company at St. Luke’s
pre-service appeals, including appeals after Medical Center in Manila, Philippines; or elsewhere, the
medical services have been provided, such as Medicare National Standard Fee. When Services are
requests for reimbursement or payment for the provided to a Covered Person by a Non-Participating
provided services. Most appeals for group health Provider, the Covered Person shall inform the Provider
benefits are post-service appeals.
of Services that the Covered Person is a Covered within the scope of the medical or dental specialty,
Person of the Company and that in order for payments education and training of the Provider; provided in a
to be made by the Company for eligible Services, such setting consistent with the required level of care; or
Provider of Services is required to file a Treatment Plan preventive Services as provided in the Plan.
with the Company as prescribed hereunder and, within
90 days after the last day on which such Services were MEMBER, ENROLLEE, OR COVERED PERSON Any
rendered, is required to submit to the Company a employee or eligible dependent of an employee, who
report of Services rendered upon such claim form or is properly enrolled in the StayWell Health Plan.
forms as the Company shall prescribe. The PARTICIPATING PROVIDERS "Participating Providers”
responsibility for having the proper Treatment Plan and shall be defined as doctors, medical groups, hospitals,
claim timely submitted to the Company shall be with skilled nursing facilities, pharmacies, dentists,
Subscriber, and the Company shall not be obligated to laboratories, and other health care facilities that: (i)
make any payment until such Treatment Plan and claim have directly, or indirectly through StayWell’s
are received and approved by the Company. agreements with other networks, entered into an
EMERGENCY The sudden and unexpected onset of a agreement with StayWell to provide Covered Services;
severe medical condition which, if not treated and (ii) are assigned from time to time by StayWell to
immediately, could result in irreparable harm, a life- participate in the StayWell provider network.
threatening situation, or permanent disability. PRE-CERTIFICATION The authorization from
FINAL INTERNAL ADVERSE BENEFIT StayWell for all hospital admissions, outpatient surgical
DETERMINATION A final internal adverse benefit procedures, and certain diagnostic tests.
determination means an adverse benefit determination RECISSION OF COVERAGE The retroactive
that has been upheld by the plan at the completion of cancellation of a health insurance policy. StayWell will
the internal appeals process. retroactively cancel your entire policy if you
FORMULARY The list of preferred prescription drugs, intentionally misrepresent on your initial application for
devices and supplies that are Covered Services under your insurance policy.
the Plan and selected for their safety, effectiveness and SCHEDULE OF BENEFITS Sets forth the benefits
affordability. The Formulary is subject to change during which will be provided to each Subscriber and to each
the Plan Year. of his or her eligible enrolled Dependents, if any, and
GRIEVANCE Any formal verbal or written expression of the extent of each benefit, including the requirements,
dissatisfaction by a Member or a Member’s Authorized limitations and maximums under which the benefits
Representative that requires follow up and/or will be provided when enrolled in this Plan for the Plan
investigation. A standard grievance must be addressed Year. The Schedule of Benefits is shown in Exhibit C of
within 30 days. All verbal or written complaints of the Certificate.
abuse, neglect, patient harm, or the risk of patient SERVICE AREA The Territory of Guam and the
harm, a violation of the Patient Rights and Commonwealth of the Northern Mariana Islands
Responsibilities, are examples of grievances. Any verbal (CNMI).
complaint requested by a member/authorized
representative to treat a complaint like a grievance will SERVICE Health care services, supplies and
be considered a grievance. equipment, or any combination thereof.
MEDICALLY NECESSARY OR MEDICAL NECESSITY

Shall be defined as services or supplies, which under
the provisions of this Agreement, are determined to be:
appropriate and necessary for the symptoms, diagnosis
or treatment of the Injury or Illness or dental condition;
provided for the diagnosis or direct care and treatment
of the Injury or Illness or dental condition; within
standards of good medical or dental practice within
the organized medical or dental community; not
primarily for the convenience of the Covered Person or
of any Provider providing Covered Services to the
Covered Person; an appropriate supply or level of
service needed to provide safe and adequate care;
YOUR RIGHTS
PRIVACY POLICY STATEMENT products or services, and processing transactions
We are required by law to: requested by you. We may also disclose PHI to
affiliates, and to business associates outside
• maintain the privacy of your Protected Health StayWell Insurance, if they need to receive PHI to
Information (PHI); provide a service to us and will agree to abide by
• provide you this notice of our legal duties and specific HIPAA rules relating to the protection of
privacy practices with respect to your PHI; and PHI. Examples of business associates are: billing
• follow the terms of this notice. companies, data processing companies, or
companies that provide general administrative
We protect your PHI from inappropriate use or
services. PHI may be disclosed to reinsurers for
disclosure. Our employees, and those of companies
underwriting, audit or claim review reasons. PHI
that help us service your StayWell insurance, are
may also be disclosed as part of a potential merger
required to comply with our requirements that protect
or acquisition involving our business in order to
the confidentiality of PHI. They may view your PHI only
make an informed business decision regarding any
when there is an appropriate reason to do so, such as
such prospective transaction.
to administer our products or services.
We will not disclose your PHI to any other company • Where Required by Law or for Public Health
for their use in marketing their products to you. Activities We disclose PHI when required by
However, as described below, we will use and disclose federal, state or local law. Examples of such
PHI about you for business purposes relating to your mandatory disclosures include notifying local
health insurance coverage. health authorities regarding particular
communicable diseases, or providing PHI to a
The main reasons for which we may use and may
governmental agency or regulator with health care
disclose your PHI are to evaluate and process any
oversight responsibilities. We may also release PHI
requests for coverage and claims for benefits you may
to a coroner or medical examiner to assist in
make or in connection with other health-related
identifying a deceased individual or to determine
benefits or services that may be of interest to you.
the cause of death.
The following describe these and other uses and
disclosures, together with some examples. • To Avert a Serious Threat to Health or Safety
We may disclose PHI to avert a serious threat to
• For Treatment We may use and disclose your PHI
someone’s health or safety. We may also disclose
to coordinate or manage your health care and any
PHI to federal, state or local agencies engaged in
related services. In addition, we may share your PHI
disaster relief as well as to private disaster relief or
with referring physicians, clinical and pathology
disaster assistance agencies to allow such entities
laboratories, pharmacies or other health care
to carry out their responsibilities in specific disaster
personnel providing you treatment.
situations.
• For Payment We may use and disclose PHI to pay
• For Health-Related Benefits or Services We may
for benefits under your health insurance coverage.
use PHI to provide you with information about
For example, we may review PHI contained on
benefits available to you under your current
claims to reimburse providers for services
coverage or policy and, in limited situations, about
rendered. We may also disclose PHI to other
health-related products or services that may be of
insurance carriers to coordinate benefits with
interest to you.
respect to a particular claim. Additionally, we may
disclose PHI to a health plan or an administrator of • For Law Enforcement or Specific Government
an employee welfare benefit plan for various Functions We may disclose PHI in response to a
payment related functions, such as eligibility request by a law enforcement official made
determination, audit and review or to assist you through a court order, subpoena, warrant,
with your inquiries or disputes. summons or similar process. We may disclose PHI
about you to federal officials for intelligence,
• For Health Care Operations We may also use and
counterintelligence, and other national security
disclose PHI for our insurance operations. These
activities authorized by law.
purposes include evaluating a request for health
insurance products or services, administering those
• When Requested as Part of a Regulatory or Legal Right to Amend Your PHI If you believe that your PHI is
Proceeding If you or your estates are involved in a incorrect or that an important part of it is missing, you
lawsuit or a dispute, we may disclose PHI about have the right to ask us to amend your PHI while it is
you in response to a court or administrative order. kept by or for us. You must provide your request in
We may also disclose PHI about you in response to writing. We may deny your request if it is not in writing
a subpoena, discovery request, or other lawful or does not include a reason that supports the request.
process by someone else involved in the dispute, In addition, we may deny your request if you ask us to
but only if efforts have been made to tell you about amend PHI that:
the request or to obtain an order protecting the
PHI requested. We may disclose PHI to any • is accurate and complete;
governmental agency or regulator with whom you • was not created by us, unless the person or entity
have filed a complaint or as part of a regulatory that created the PHI is no longer available to make
agency examination. the amendment;
• Other Uses of PHI Other uses and disclosures of • is not part of the PHI kept by or for us; or
PHI not covered by this notice and permitted by
the laws that apply to us will be made only with • is not part of the PHI, which you would be
your written authorization or that of your legal permitted to inspect and copy.
representative. If we are authorized to use or Right to a List of Disclosures You have the right to
disclose PHI about you, you or your legally request a list of disclosures we have made of PHI about
authorized representative may revoke that you. This list will not include disclosures made for
authorization, in writing, at any time, except to the treatment, payment, and health care operations, for
extent that we have taken action relying on the purposes of national security, made to law
authorization or if the authorization was obtained enforcement or to corrections personnel or made
as a condition of obtaining your health insurance pursuant to your authorization or made directly to you.
coverage. You should understand that we will not To request this list, you must submit your request in
be able to take back any disclosures we have writing. Your request must state the time period from
already made with authorization. which you want to receive a list of disclosures. The
time period may not be longer than six years and may
Your Rights Regarding Personal Health not include dates before February 26, 2003. Your
Information We Maintain About You request should indicate in what form you want the list
The following are your various rights as a consumer (for example, on paper or electronically). The first list
under HIPAA concerning your PHI. Should you have you request within a 12-month period will be free. We
questions about a specific right, please write to the may charge you for responding to any additional
administrator of your health insurance coverage. requests. We will notify you of the cost involved and
you may choose to withdraw or modify your request at
Right to Inspect and Copy Your PHI In most cases, you that time before any costs are incurred.
have the right to inspect and obtain a copy of the PHI
that we maintain about you. To inspect and obtain a Right to Request Restrictions You have the right to
copy of your PHI, you must submit your request in request a restriction or limitation on PHI we use or
writing. To receive a copy of your PHI, you may be disclose about you for treatment, payment or health
charged a fee for the costs of copying, mailing or other care operations, or that we disclose to someone who
supplies associated with your request. However, may be involved in your care or payment for your care,
certain types of PHI will not be made available for like a family member or friend. While we will consider
inspection and copying. This includes psychotherapy your request, we are not required to agree to it. If we
notes; and also includes PHI collected by us in do agree to it, we will comply with your request. To
connection with, or in reasonable anticipation of any request a restriction, you must make your request in
claim or legal proceeding. writing. In your request, you must tell us (1) what
information you want to limit; (2) whether you want to
In very limited circumstances we may deny your limit our use, disclose or both; (3) to whom you want
request to inspect and obtain a copy of your PHI. If we the limits to apply (for example, disclosures to your
do, you may request that the denial be reviewed. The spouse or parent). We will not agree to restrictions on
review will be conducted by an individual chosen by us PHI uses or disclosures that are legally required, or
who was not involved in the original decision to deny which are necessary to administer our business.
your request. We will comply with the outcome of that
review.
Right to Request Confidential Communications If you are the spouse of an employee, you will become
You have the right to request that we communicate a qualified beneficiary if you lose your coverage under
with you about PHI in a certain way or at a certain the group health plan because any of the following
location if you tell us that communication in another qualifying events happens:
manner may endanger you. For example, you can ask
that we only contact you at work or by mail. To request • Your spouse dies;
confidential communications, you must make your • Your spouse’s hours of employment are reduced;
request in writing and specify how or where you wish
to be contacted. We will accommodate all reasonable • Your spouse’s employment ends for any reason
requests. other than his or her gross misconduct;
Right to File a Complaint If you believe your privacy • Your spouse becomes entitled to Medicare benefits
rights have been violated, you may file a complaint (under Part A, Part B, or both); or
with us. Please contact StayWell Insurance HIPAA • You become divorced or legally separated from
Privacy Officer, P.O. Box CZ Hagåtña, Guam 96932. All your spouse.
complaints must be submitted in writing. You will not
be penalized for filing a complaint. Your dependent children will become qualified
beneficiaries if they lose coverage under the group
health plan because any of the following qualifying
CONTINUATION COVERAGE events happens:
RIGHTS UNDER COBRA • The parent-employee dies;
The right to COBRA continuation coverage was
created by a federal law, the Consolidated Omnibus • The parent-employee’s hours of employment are
Budget Reconciliation Act of 1985 (COBRA). COBRA reduced;
option is available to groups with more than 20 • The parent-employee’s employment ends for any
employees (part time and full-time). StayWell is not a reason other than his or her gross misconduct;
COBRA administrator. COBRA continuation coverage
can become available to you when you would • The parent-employee becomes entitled to
otherwise lose your group health coverage. It can also Medicare benefits (Part A, Part B, or both);
become available to other members of your family
• The parents become divorced or legally separated;
who are covered under the Plan when they would
or
otherwise lose their group health plan coverage.
• The child stops being eligible for coverage under
What is COBRA Continuation Coverage? the plan as a "dependent child".
COBRA continuation coverage is a continuation of If your employer offers Retiree coverage, sometimes,
group health plan coverage when coverage would filing a proceeding in bankruptcy under title 11 of the
otherwise end because of a life event known as a United States Code can be a qualifying event. If a
"qualifying event." After a qualifying event, COBRA proceeding in bankruptcy is filed with respect to your
continuation coverage must be offered to each person Employer, and that bankruptcy results in the loss of
who is a "qualified beneficiary." You, your spouse, and coverage of any retired employee covered under the
your dependent children could become qualified group health plan, the retired employee will become a
beneficiaries if coverage under the group health plan is qualified beneficiary with respect to the bankruptcy.
lost because of the qualifying event. Under the group The retired employee’s spouse, surviving spouse, and
health plan, qualified beneficiaries who elect COBRA dependent children will also become qualified
continuation coverage must pay for COBRA beneficiaries if bankruptcy results in the loss of their
continuation coverage. coverage under the group health plan.
If you are an employee, you will become a qualified
When is COBRA Coverage Available?
beneficiary if you lose your coverage under the group
health plan because either one of the following The group health plan will offer COBRA continuation
qualifying events happens: coverage to qualified beneficiaries only after the health
insurance issuer has been notified that a qualifying
• Your hours of employment are reduced, or
event has occurred. When the qualifying event is the
• Your employment ends for any reason other than end of employment or reduction of hours of
your gross misconduct. employment, death of the employee, or the
employee’s becoming entitled to Medicare benefits Administration to be disabled and you notify the health
(under Part A, Part B, or both), the Employer must insurance issuer in a timely fashion, you and your
notify the health insurance issuer of the qualifying entire family may be entitled to receive up to an
event. additional 11 months of COBRA continuation coverage,
for a total maximum of 29 months. The disability would
You Must Give Notice of Some Qualifying Events have to have started at some time before the 60th day
of COBRA continuation coverage and must last at least
For the other qualifying events (divorce or legal until the end of the 18-month period of continuation
separation of the employee and spouse or a dependent coverage. In order to qualify for this extension you
child’s losing eligibility for coverage as a dependent must provide a copy of your Disability Award letter that
child), you must notify the health insurance issuer is received from the Social Security Administration
within 60 days after the qualifying event occurs. prior to the end of your COBRA continuation period to
the health insurance issuer.
How is COBRA Coverage Provided?
Once the health insurance issuer receives notice that a Second qualifying event extension of 18-month
qualifying event has occurred, COBRA continuation period of continuation coverage
coverage will be offered to each of the qualified
If your family experiences another qualifying event
beneficiaries. Each qualified beneficiary will have an
while receiving 18 months of COBRA continuation
independent right to elect COBRA continuation
coverage, the spouse and dependent children in your
coverage. Covered employees may elect COBRA
family can get up to 18 additional months of COBRA
continuation coverage on behalf of their spouses, and
continuation coverage, for a maximum of 36 months,
parents may elect COBRA continuation coverage on
if notice of the second qualifying event is properly
behalf of their children.
given to the health insurance issuer. This extension
COBRA continuation coverage is a temporary may be available to the spouse and any dependent
continuation of coverage. When the qualifying event is children receiving continuation coverage if the
the death of the employee, the employee’s becoming employee or former employee dies, becomes entitled
entitled to Medicare benefits (under Part A, Part B, or to Medicare benefits (under Part A, Part B, or both), or
both), your divorce or legal separation, or a dependent gets divorced or legally separated, or if the dependent
child’s losing eligibility as a dependent child, COBRA child stops being eligible under the group health plan
continuation coverage lasts for up to a total of 36 as a dependent child, but only if the event would have
months. When the qualifying event is the end of caused the spouse or dependent child to lose
employment or reduction of the employee’s hours of coverage under the group health plan had the first
employment, and the employee became entitled to qualifying event not occurred.
Medicare benefits less than 18 months before the
qualifying event, COBRA continuation coverage for
qualified beneficiaries other than the employee lasts THE HEALTH CARE PROMPT PAYMENT
until 36 months after the date of Medicare entitlement. ACT OF 2000
For example, if a covered employee becomes entitled § 9902. Prompt Payment for Health Care and Health
to Medicare 8 months before the date on which his Insurance Benefits.
employment terminates,
(a) This Section applies to Health Plan Administrators,
COBRA continuation coverage for his spouse and as defined by this Chapter, organized and operating
children can last up to 36 months after the date of under the laws of Guam.
Medicare entitlement, which is equal to 28 months
after the date of the qualifying event (36 months minus (b) Health Plan Administrators shall reimburse a Clean
8 months). Otherwise, when the qualifying event is the Claim, or any portion thereof, submitted by a patient or
end of employment or reduction of the employee’s Health Care Provider, that is eligible for payment and
hours of employment, COBRA continuation coverage not contested or denied not more than 45 calendar
generally lasts for only up to a total of 18 months. days after receiving the Clean Claim filed in writing.
There are two ways in which this 18-month period of
COBRA continuation coverage can be extended. (c) If a claim is contested or denied, or requires more
time for review by the Health Plan Administrator, the
Health Plan Administrator shall notify the Health Care
Disability extension of 18-month period of
Provider in writing not more than 30 calendar days
continuation coverage after receiving a claim filed for payment. The notice
If you or anyone in your family covered under the shall identify the contested or denied portion of the
group health plan is determined by the Social Security
claim and the specific reason for contesting or denying added by the Health Plan Administrator to the amount
the claim, and may request additional information. of the unpaid Clean Claims due the Health Care
Requests for information on a contested or denied provider.
claim, or portion thereof, shall be reasonable and
relevant to the determination of why the claim is being (i) Interest shall only apply to the principal portion of
contested or denied. In no event may a claim be the claim.
contested or denied for the lack of information that (j) The provisions of this Section shall not apply to the
has no factual impact upon the Health Plan payment or reimbursement of any claim, or portion
Administrator’s ability to adjudicate the claim. thereof, involving a Coordination of Benefits between
(d) If information received pursuant to a request for multiple payers of a claim.
additional information is satisfactory to warrant paying § 9903. Timely Filing of Accurate Claims.
the Clean Claim, the Clean Claim shall be paid not
more than 45 calendar days after receiving the (a) This Section applies to Health Care Providers, as
additional information in writing. defined by this Act, duly certified, licensed, or
organized and operating under the laws of Guam.
(e) The payment of a Clean Claim under this Section
shall be effective upon the date of postmark of the (b) All claims submitted for reimbursement must be
mailing. submitted on a UB-04, HCFA 1500, ADA claim, or other
billing document generally accepted by Health Plan
(f) Health Care Providers shall be responsible for Administrators. Claims may be submitted electronically
obtaining proof in writing that a specific claim was if such a transmittal arrangement has been agreed to
delivered to a Health Plan Administrator on a specific by the Health Plan Administrator.
date for determining the time periods for the purposes
of prompt payment. (c) Health Care Providers shall be responsible for the
accuracy of all claims filed. Duplicate claims,
(g) Notwithstanding any provisions to the contrary, unbundled claims, or fee-for-service claims billed in a
interest shall be allowed to accrue at a rate of 12% per capitated arrangement, may not be submitted and
annum as damages for money owed by a Health Plan cannot be considered for prompt payment in
Administrator for payment of a Clean Claim, or portion accordance with the provisions of this Act.
thereof, that exceeds the applicable reimbursement
time limitations under this Section, including applicable (d) Should a Health Care Provider fail to submit a
costs for collecting past due payments as provided in § response to a reasonable request for additional
9905 of this Article, as follows: information on a contested or disputed claim, within
45 days from the date of request for such additional
(1) for an uncontested Clean Claim: information, no interest shall accrue to the claim or
(i) filed in writing, interest from the first portion thereof eligible for payment. For purposes of
calendar day after the 45-day period in this Subsection, should a Health Care Provider be a
§ 9902(b); or hospital, then such a hospital provider shall be allowed
to submit a response to a reasonable request for
(2) for a contested claim, or portion thereof, filed additional information on a contested or disputed
in writing: claim within 90 days from the date of request for such
additional information.
(i) for which notice was provided under
§ 9902(c), interest from the first calendar (e) In order for a Health Care Provider to receive
day 45 days after the date the additional interest for the late payment of a claim as provided in §
information is received; or 9902, a claim for health services rendered must be
submitted within 45 days from the date the health
(ii) for which notice was not provided, but not service was provided.
within the time specified under § 9902(c),
interest from the first calendar day after the (f) With the exception of those claims that involve the
claim is received. coordination of benefits, all claims for payment must
be submitted by the Health Care Provider within 90
(h) Each Health Care Provider shall notify the Health days from the date that health services were rendered.
Plan Administrator and patient in writing of all claims Any claim not submitted by the Health Care Provider
for which they intend to charge interest. Any interest within 90 days from the date that health services were
that accrues as a result of the delayed payment of a rendered shall not be the financial responsibility of
Clean Claim, or any portion thereof, in accordance either the Health Plan Administrator or the patient.
with the provisions of this Act shall be automatically
§ 9904. Billing of Patients Allowed. (2) Two (2) percent from the 61st day through the
120th calendar day; and
(a) No patient receiving care from a Health Care
Provider, may be billed for the same Clean Claim, or (3) Two and one-half (2.5) percent after the 120th
portion thereof, submitted for payment to a Health calendar day.
Plan Administrator, unless the provider has elected to
terminate that person’s efforts to collect interest (d) For paper claims, the interest payable shall be at a
penalties as provided for in § 9902(g) of this Act, or a monthly rate of:
period of 90 days has lapsed from the date of (1) Two and one-half (2.5) percent from the 41st day
submission of a Clean Claim for payment. This through the 60th calendar day;
provision shall not apply to any Clean Claim or portion
of a Clean Claim that is due and payable by the patient (2) Three (3) percent from the 61st day through the
as a benefit limitation, deductible, co-payment, non- 120th calendar day; and
covered benefit, patient share, or personal comfort or (3) Three and one-half (3.5) percent after the 120th
convenience item. calendar day.
(b) A Health Care Provider may not charge more than (e) This section shall not apply to claims if the health
12% interest per annum to any patient as a penalty for insurance issuer:
their failure to make prompt payment of a Clean Claim,
or portion thereof, for which the patient is responsible (1) Notifies the person submitting the claim within
for paying. 30 calendar days after the receipt of the claim
that the legitimacy of the claim or the
(c) A Healthcare Provider may not charge both the appropriate amount of reimbursement is in
Health Plan Administrator and the patient interest dispute;
penalties for the same Clean Claim, or portion thereof,
submitted for payment to either party. (2) States, in writing, to the person the specific
reasons why the legitimacy of the claim, a
portion of the claim, or the appropriate amount
PUBLIC LAW NO. 20-88 of reimbursement is in dispute; and
To mandate prompt payment for health care services (3) Pays any undisputed portion of the claim within
performed in the CNMI and to authorize CNMI health 40 calendar days of the receipt of the claim.
care service providers to impose penalties on late
payments received for clean claims; to set uniform (f) The health insurance issuer shall process the
standards for the processing of electronic claims; and disputed portion of the claim within 40 calendar days
for other purposes after receipt of all reasonable and necessary
documentation.
§ 103. Prompt Payment
(g) If a health insurance issuer fails to comply with the
(a) Within 180 calendar days of the effective date of requirements of subsection (f) of this section, it shall
this Act, for covered services rendered to its members, pay interest at the rates set forth in subsections (c) and
a health insurance issuer shall reimburse any person (d) of this section beginning on the 41st calendar day
entitled to reimbursement under the health plan within after the filing of the receipt of the documentation as
forty (40) calendar days after the date of receipt on a provided in subsection (f) of this section.
clean claim.
(h) A health insurance issuer shall allow a provider a
(b) If a health insurance issuer fails to comply with minimum of 180 calendar 28 days from the date a
subsection (a) of this section, the health insurance covered service is rendered or the date of inpatient
issuer shall pay interest beginning on the forty-first discharge to submit a claim for reimbursement for the
(41st) calendar day after the receipt of the claim if the service.
date of payment is not within forty (40) calendar days.
A formal claim by the person filing the original claim (i) There shall be a rebuttable presumption that a claim
shall not be required. has been received by a health insurance issuer:
(c) For electronic claims, the interest payable shall be at (1) Within 15 business days from the date the
a monthly rate from the receipt of claim of: provider or person entitled to reimbursement
placed the claim in the United States mail;
(1) One and one-half (1.5) percent from the 41st day
through the 60th calendar day;
(2) Within 8 working hours if the claim was mother, from discharging the mother or her newborn
submitted by the provider or provider’s agent earlier than 48 hours (or 96 hours as applicable). In
electronically and was not returned to the any case, plans and issuers may not, under Federal
provider by a health care clearinghouse or law, require that a provider obtain authorization from
returned to the provider by the insurer if the plan or the insurance issuer for prescribing a
submitted directly to the health insurer; or length of stay not in excess of 48 hours (or 96 hours).
(3) On the date recorded by the courier if the claim
was delivered by courier.
NOTICE REGARDING WOMEN’S HEALTH AND
(j) Each health insurance issuer shall provide a manual CANCER RIGHTS ACT
or other document that sets forth the claims Under the group health plan, coverage will be
submission procedures to all contracting providers at provided to a person who is receiving benefits for a
the time of contracting and 30 calendar days prior to medically necessary mastectomy and who elects
any changes in the procedure. breast reconstruction after the mastectomy for:
(k) A health insurance issuer shall maintain a written or • reconstruction of the breast on which a
electronic record of the date of receipt of a claim. The mastectomy has been performed;
person submitting the claim shall be entitled to inspect
the record on request and to rely that record or on any • surgery and reconstruction of the other breast to
other admissible evidence as proof of the fact of receipt produce a symmetrical appearance;
of the claim, including electronic facsimile confirmation
• prostheses; and
of receipt of a claim.
• treatment of physical complications of all stages
(l) A health insurance issuer shall not be in violation of
of mastectomy, including lymphedemas.
this chapter if its failure to pay a claim in accordance
with the time periods provided in this chapter is caused:
(1) In material part by the person submitting the QUALIFIED MEDICAL CHILD SUPPORT
claim; or ORDERS
(2) By impossibility due to matters beyond the health The Staywell Insurance Plan recognizes State court
insurer’s reasonable control, such as an act of and administrative orders directing a participant to
God, insurrection, strike, fire, or power outages. provide health benefit coverage for dependent
children even if the participant does not have custody
(m) This section shall not apply to claims for which of these children, if a court order is a Qualified
payment has been or will be made directly to health Medical Child Support Order (QMCSO). This shall
care providers pursuant to a negotiated reimbursement include enrolling the employee, if eligible, and the
arrangement requiring uniform or periodic interim relevant Child if eligible, outside a regularly scheduled
payments to be applied against the health insurer’s open enrollment period. If the order is not a QMCSO,
obligation on such claims then the Employee must wait until the next open
(n) Nothing in this chapter shall prevent a health care enrollment period to enroll. Participants and
provider and health insurance issuer from entering into beneficiaries can obtain a copy of the procedures
a services agreement with a stricter time frame for governing QMCSO, without charge, from the Group
payment and/or penalty schedule Health Benefit Plan Administrator.
NEWBORN’S AND MOTHER’S HEALTH INTERPRETIVE SERVICES

PROTECTION ACT As a StayWell member you have the right to
Group health plans and health insurance issuers interpretive services that are prescribed by law.
generally may not, under Federal law, restrict benefits StayWell Insurance assures that members with limited
for any hospital length of stay in connection with English proficiency (LEP), hearing or speech
childbirth for the mother or newborn child to less than impairments are provided interpretive services, such
48 hours following a vaginal delivery, or less than 96 as foreign language, American Sign Language, or use
hours following a cesarean section. However, Federal of TDD/TTY lines, when appropriate. Every attempt is
law generally does not prohibit the mother’s or made to provide services in any language needed by
newborn’s attending provider, after consulting with the the member.
Standards for Culturally and Linguistically There are two types of advance directives. You can
Appropriate Notices choose to have one or both:
In compliance with Paragraph O of ERISA § 2560.503- 1. A proxy directive is also known as a durable power
1, (1) Requirements. (i) The Plan must provide oral of attorney for health care. With this, you name a
language services (such as a telephone customer person to make health care decisions for you if you
assistance hotline) that include answering questions in are unable to make them yourself. A proxy directive
any applicable non-English language and providing does not allow anyone to make legal or financial
assistance with filing claims and appeals in any decisions for you.
applicable non-English language; (ii) The Plan must
2. An advance directive is also known as a living will.
provide, upon request, a notice in any applicable
In this, you explain the situations in which you
non-English language; and (iii) The Plan must include
would want or not want, life-sustaining treatment,
in the English versions of all notices, a statement
and the types of such treatment you would want or
prominently displayed in any applicable non-English
not want. You can also explain your beliefs, values,
language clearly indicating how to access the language
and the general care and treatment you prefer.
services provided by the plan.
You decide what goes in an advance directive and can
(2) Applicable non-English language. With respect to
make it as personalized or as general as you like. You
an address in any United States county to which a
can change your advance directive at any time. You
notice is sent, a non-English language is an applicable
should make sure others know you have an advance
non-English language if ten percent (10%) or more of
directive. If you choose to designate a Medical Power
the population residing in the county is literate only in
of Attorney, that person should be made aware of your
the same non-English language, as determined in
advance directive or living will as well.
guidance published by the Secretary of Health and
Human Services. You can obtain an Advance Directive Form in a doctor’s
office, hospital, law office, nursing home, or online.
The Guam legislature provided statutes governing the
ADVANCE DIRECTIVES content and use of a living will declaration. Refer to
Guam Health and Safety Code, Title 10, Div. 4, Chapter
Planning Your Advance Directive §9110 to §9117 for specific information. If you have
An advance directive (also known as a living will) is a questions about Advance Directives, you may call
legal document that provides written instructions to StayWell at (671) 477-5091 or speak to your doctor.
your doctor, family, or health care representative about Once you have completed your advance directive, ask
the type of medical care you want–and do not want–if your doctor to put the form in your file. You can also
you cannot make decisions for yourself. You should talk to your doctor about the decision-making process
think about having an advance directive no matter of creating your advance directive or living will.
what age or health condition. Together, you can make decisions that will put your
An advance directive becomes effective only when mind at ease.
your doctor has evaluated you and has determined If you have signed an advance directive, and you
that you are unable to understand your diagnosis or believe that a doctor or hospital did not follow the
treatment options. Your doctors, family, or your health instructions in it, you may file a grievance with
care representative should have copies of your StayWell. Refer to the grievance section of this
advance directive(s), so your medical wishes are handbook or contact Customer Care at (671) 477-5091
honored. for more information.
You can also name someone, known as a Medical
Power of Attorney, to make medical decisions on your
behalf if you are unable to.
Creating Your Advance Directive

StayWell recommends all of our plan members take
the time to create an advance directive, assign a
Medical Power of Attorney, and provide their advance
directive to their primary care physician.
notes
notes
OFFICE
DIRECTORY
GUAM
Location: 520 Route 8 Maite, Guam 96910
Hours: 8:00 a.m. - 5:00 p.m. Monday – Friday
Phone Line: (671) 477-5091
Fax Line: (671) 477-5096
Toll Free Line: 1-866-782-9955
Extension Departments: 1100 Administration
1120 Customer Care (Health)
1140 Informed Choice (Pre-certification and referrals)
1150 Enrollment
1180 Provider Relations
1185 Health Management
1190 Sales & Marketing
After Hours Access: available 5:00 p.m. - 8:00 p.m
Informed Choice (Pre-Certification): (671) 971-1190
SAIPAN
Location: 1st Floor, RJ Commercial Building, Suite 2
Chalan Monsignor Guerrero Road Dandan, Saipan 96950
Hours: 8:00 a.m. - 5:00 p.m. Monday – Friday
Phone Line: (670) 323-4260
Fax Line: (670) 323-4263
PHILIPPINES
Location 1: St. Luke’s Medical Center - Quezon City
Rm. 1104 - 1105 North Tower, Cathedral Heights Bldg. Complex
St. Luke’s Medical Center, 279 E. Rodriguez Sr. Ave.
Quezon City, Philippines 1112
Phone Line: (+632) 8723-0101 local 5145
Fax Line: (+632) 8723-3349
Mobile Line: (+63) 8919-394-6690 (during office hours only)
Location 2: St. Luke’s Medical Center - Global City

Unit 1135 Medical Arts Bldg.,
St. Luke’s Medical Center Bonifacio Global City,
Taguig Philippines 1630
Phone Line: (+632) 8789-7700 local 7135
Fax Line: (+632) 8403-7061
Mobile Line: (+63) 8917-628-1760 (Dr. Edwin Denis Magno)
Hours: 7:00 a.m. - 4:00 p.m Monday – Friday
staywellguam.com
staywellguam.com

Member Handbook 2021101409

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Member Handbook 2021101409

Uploaded by

Copyright:

Available Formats

See how far we’ll go.

See how far we’ll go.

ACCESSING STAYWELL CARE

Review Type Standard Timeframe of Notification

Urgent pre-service 72 hours

24 Hour Hotline Emergency Contact Numbers

Guam Alternative In case of an emergency please call 911

For reimbursement of eligible • Diagnosis code (ICD10) • Name of prescribing

REVIEW AND APPEALS

MEDICALLY NECESSARY OR MEDICAL NECESSITY

NEWBORN’S AND MOTHER’S HEALTH INTERPRETIVE SERVICES

Creating Your Advance Directive

Location 2: St. Luke’s Medical Center - Global City

Hours: 7:00 a.m. - 4:00 p.m Monday – Friday

You might also like