Congresswoman Madeleine Z. Bordallo announced today that, effective November 17, 2005, the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (IOM) has been updated to take into account payment reimbursement claims that may be validly filed and processed for Medicare beneficiaries residing in Guam who receive emergency treatment in qualifying Philippine hospitals.

The IOM is the primary authoritative source for operating instructions, policies, and procedures for the Medicare program. CMS personnel, contractors, State and territorial governments, hospitals, and health care providers and professionals, regularly consult the IOM in administering the various components of the Medicare program and in processing Medicare payments. The IOM, published and maintained by CMS, is updated as necessary to reflect policy changes or to provide for clarifications important to program administration.

Since arriving in Congress in 2003, Congresswoman Bordallo has worked with CMS to clarify the criteria and process for Medicare approval of payments for medical treatment received in Philippine hospitals. U.S. law prohibits Medicare payments for services received outside of Guam, or anywhere else in the United States, except in certain and limited circumstances.

One such exception is payment for medically necessary treatment involving emergency inpatient services if such services cannot be provided to the patient by Guam Memorial Hospital at the time of the emergency, and the patient, who is a Medicare beneficiary, is referred to a hospital in the Philippines.

Hospitals in the Philippines are closer to and more accessible from Guam than facilities in Hawaii, the nearest U.S. jurisdiction to Guam where advanced health care services are available. The proximity of the Philippines to Guam satisfies the general requirements in law that provide for the “foreign hospital” exception. Prior to yesterday’s update, the IOM only reflected reimbursement procedures for foreign hospitals located in Canada and Mexico, where Medicare beneficiaries residing or located in communities along the U.S.-Canadian and U.S.-Mexican borders are typically referred to receive emergency health care. The IOM had not taken into account the potential for referrals from Guam to the Philippines, and as result, complicated the processing of Medicare payments for Guam-referred beneficiaries. Recent cases of Medicare beneficiaries having been referred to the Philippines for emergency treatment helped demonstrate the need for a clarification to be made in the IOM.

“I thank Dr. McClellan, CMS Administrator, for understanding the medical needs of Guam’s Medicare beneficiaries and for working with me to update Medicare policy. The change to the CMS manual will smooth the processing of Medicare claims for emergency treatment in the Philippines,” said Congresswoman Bordallo.

“Medicare coverage in the Philippines will help Guam residents by reducing out-of-pocket expenses, including travel costs associated with emergency health care,” Bordallo stated in explaining that Medicare beneficiaries will no longer have to travel to Hawaii or to the U.S. Mainland on an emergency referral to guarantee Medicare reimbursement.

Congresswoman Bordallo continues to work with CMS to clarify other policies relating to Medicare and Medicaid program administration. This work includes an ongoing review of all potential off-island referrals, both emergency and non-emergency in nature, to help ensure the IOM and CMS policy accurately reflects current law and the interests of beneficiaries residing in Guam.

FOR MORE INFORMATION

The official CMS notification of this IOM update is available at:
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3781.pdf

The IOM change request is available at:
http://www.cms.hhs.gov/manuals/pm_trans/R38bp.pdf

The entire IOM is available at:
http://www.cms.hhs.gov/manuals/