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Applies if care un available at nearest U.S. facility

By Haidee V. Eugenio Reporter SAIPAN, CNMI (Saipan Tribune, Aug. 1, 2011) – U.S. Centers for Medicare and Medicaid Services administrator Dr. Donald M. Berwick has confirmed that Medicare pays for emergency and non-emergency inpatient services provided in the Philippines for CNMI patients if, among other things, the foreign hospital is closer to the patient's home than the nearest U.S. hospital that can treat the patient's medical condition.

Delegate Gregorio Kilili Sablan, Senate President Paul Manglona (Ind-Rota), and Sen. Ralph Torres (R-Saipan) separately welcomed the clarification from the Medicare administrator on Medicare coverage outside the United States.

Medicare is a U.S. social insurance program that provides health insurance coverage to people who are at least 65 years old and those younger but with permanent disability.

"I'm glad we have the response we have been waiting for," Torres, chairman of the Senate Committee on Health and Welfare, told Saipan Tribune yesterday.

Sablan, for his part, said there is no change in existing policy, "but clearly the availability of Medicare insurance to cover treatment in the Philippines was not well known or understood in the NMI."

He hopes that the information that Medicare shared will "result in improved access to health care and that it will help to offset some of the growing difficulties the Commonwealth Health Center is having providing service to seniors and others who qualify for Medicare."

The delegate also said with the state of emergency at CHC, seniors and others with Medicare insurance may need to get treatment in the Philippines.

"Dr. Berwick's statement makes clear that this option is available," he added.

Torres said the clarification from the Medicare administrator is a big step, and the sooner agencies and officials get together to work out the details, the better for CNMI patients.

"It will be a lengthy process. For example, we still need to know which hospitals in the Philippines could accept Medicare patients, and the specific types of medical services. We will be working closely with Delegate Sablan's office, the CNMI Department of Public Health, the administration, and Medicare to make sure CNMI patients will get Medicare coverage in the Philippines," he added.

Berwick wrote a July 21 response letter to Sablan, containing the clarification.

"Medicare pays for emergency services and non-emergency inpatient services provided in the Philippines to residents of the Northern Mariana Islands depending on certain circumstances," he said.

Berwick said these include the location of the beneficiary at the time of the emergency, the accessibility to the nearest adequately equipped hospital within the United States, and requirements related to licensure and accreditation of the hospital outside the U.S.

Manglona and Torres, along with Senate Vice President Jude Hofschneider (R-Tinian) and Sen. Frank Cruz (R-Tinian), raised the question of Medicare coverage during their meeting with senior officials of the U.S. Department of Health and Human Services in Washington, D.C. in March.

Days after receiving Berwick's letter, Sablan wrote to the CNMI senators on July 27, informing them of the result of his office's research on the matter.

Sablan said travel to the Philippines would be an attractive alternative for Medicare patients from the CNMI who now go to Hawaii or the U.S. mainland for care, which is both expensive and a physical hardship for seniors.

The Philippines is only about three hours away from the CNMI. Travel to Hawaii is more than seven hours.

In his July 27 letter to the senators, Sablan expounded on Berwick's letter.

He said with respect to the location of the beneficiary, if an individual is physically present in the CNMI when a medical emergency arises, the individual may go to the Philippines for treatment as long as the reason for departure is specifically to obtain treatment and as long as there is no closer U.S. hospital that is adequately equipped and available to treat the illness or injury.

"The same is true for non-emergency conditions, although it is considered advisable that residents of the Northern Mariana Islands traveling to the Philippines for non-emergency services contact their Medicare contractor prior to travel to confirm that the specific services will be covered by Medicare," Sablan told the senators.

Manglona said the CNMI government would save money and time by sending patients to the Philippines, and a shorter travel time between the CNMI and the Philippines will be a big relief especially to seniors.

Torres also said some Hawaii and Guam facilities may have already stopped accepting CNMI patients with Medicare coverage, but he said he will get more clarification from the Department of Public Health this week.

Both Torres and Manglona said DPH or the administration must really need to look into the Medicare coverage especially with the creation of a health care corporation.

"We already asked the acting governor (Lt. Gov. Eloy S. Inos) to start sending names to the Senate for nominees to the healthcare corporation board rather than wait for the last minute," Torres added.

Sablan also said that the Centers for Medicare and Medicaid Services informed him that a medical referral from a U.S. hospital such as the Commonwealth Health Center is not required for Medicare to cover either emergency or non-emergency services in the Philippines.

But he also said that a referral is not a guarantee to the beneficiary that Medicare will pay for the services.

"A medical referral, however, would be taken into account in making the determination of whether the services outside the United States were reasonable and necessary and whether CHC was adequately equipped to provide those services," the delegate said.

Sablan said for emergency inpatient services, the hospital receiving payment must be licensed or approved by the appropriate agency in the Philippines, but it is not necessary that it be accredited by any United States accrediting body.

He said for non-emergency inpatient services, Medicare will pay for services provided by a hospital that is accredited by the Joint Commission on Accreditation of Health Organizations or under standards essentially equivalent to those of the JCAHO.

Berwick said specific information on Medicare coverage for such services may be found in the Medicare regulations implementing the payment to foreign hospital provisions of section 1814(f) and the exclusion in section 1862(a)(4) of the Social Security Act, codified at 42 CFR Part 424, Subpart H and 42 CFR 411.9.

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