TITLE 75: OFFICE OF THE GOVERNOR

Chapter 50. TITLE 75: OFFICE OF THE GOVERNOR

TITLE 75: OFFICE OF THE GOVERNOR CHAPTER 75-50 MEDICAL REFERRAL PROGRAM RULES AND REGULATIONS Part 001 General Provisions Referral § 75-50-001 Introduction § 75-50-415 Denial of a Presented § 75-50-005 Medical Referral Services Referral Case Office § 75-50-010 Medical Referral Services Part 500 Emergency Transfers from Rota Part 100 Medical Referral § 75-50-501 Emergency Evacuation Committee § 75-50-505 Authority to Transfer § 75-50-101 Composition § 75-50-510 Responsibility for Payment § 75-50-105 Chairperson of Medical Care § 75-50-110 Case Review § 75-50-115 Final Decisions Part 600 Follow-up; Exclusions; § 75-50-120 Review of Emergency Emergencies Medical Referral Cases § 75-50-601 Follow-up Medical § 75-50-125 Modifications to Rules and Appointments Regulations § 75-50-605 Medical Referral Program § 75-50-130 Approval of Reports Exclusions § 75-50-610 Humanitarian and Emergency Part 200 Program Eligibility Provisions § 75-50-201 Introduction § 75-50-205 Medical Criteria Part 700 Referral Fees § 75-50-210 Residency Criteria § 75-50-701 Payment of Medical Referral § 75-50-215 Persons Ineligible to Costs Participate in the Program § 75-50-705 Assignment of Rights § 75-50-710 Utilization Review Part 300 Medical Referral Services § 75-50-715 Lifetime Limit Covered Benefits § 75-50-301 Introduction Part 800 Limited Government § 75-50-305 Medical Costs Liability § 75-50-310 Ancillary Costs § 75-50-801 Statutory Exemption § 75-50-315 Transportation Costs § 75-50-805 Medical Referral Program § 75-50-320 Patient Escorts Not Responsible for Unauthorized Services § 75-50-325 Maintenance Costs Part 900 Miscellaneous Provisions Part 400 Procedures for Medical § 75-50-901 Penalties for Violations of Referral Rules and Regulations § 75-50-401 Non-Emergency Referral § 75-50-905 Severability Cases § 75-50-405 Emergency Referral Appendix A Referral Health Care Procedures Facilities § 75-50-410 Approval for Medical Subchapter Authority: 1 CMC § 2605; 3 CMC § 2824(v); E.O. 2013-9 (May 2, 2013).

TITLE 75: OFFICE OF THE GOVERNOR Subchapter History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Amdts Adopted 32 Com. Reg. 30092 (Apr. 19, 2010); Amdts Proposed 32 Com. Reg. 30062 (Feb. 19, 2010); Amdts Adopted 29 Com. Reg. 26511 (Apr 16, 2007); Amdts Proposed 28 Com. Reg. 26211 (Oct. 30, 2006); Amdts Emergency and Proposed 28 Com. Reg. 26308 (Nov. 30, 2006) (effective for 120 days from November 13, 2006);* Amdts Emergency and Proposed 27 Com. Reg. 25187 (Nov. 25, 2005) (effective for 120 days from November 23, 2005);* Amdts Emergency and Proposed 27 Com. Reg. 24705 (Aug. 22, 2005) (effective for 120 days from Aug. 19, 2005);* Amdts Adopted 27 Com. Reg. 24681 (July 20, 2005); Amdts Emergency and Proposed 27 Com. Reg. 24099 (Mar. 17, 2005) (effective for 120 days from March 14, 2005); Amdts Emergency and Proposed 26 Com. Reg. 22836 (Sept. 24, 2004) (effective for 120 days from Sept. 21, 2004);* Amdts Adopted 26 Com. Reg. 22867 (July 26, 2004); Amdts Emergency and Proposed 26 Com. Reg. 22500 (May 24, 2004) (effective for 120 days from Apr. 27, 2004); Amdts Adopted 26 Com. Reg. 21894 (Feb. 23, 2004); Amdts Emergency and Proposed 26 Com. Reg. 21531 (Jan. 22, 2004) (effective for 120 days from Jan. 14, 2004); Amdts Adopted 24 Com. Reg. 19032 (Feb. 28, 2002); Amdts Proposed 23 Com. Reg. 18351 (Sept. 24, 2001); Amdts Adopted 22 Com. Reg. 17349 (July 20, 2000); Amdts Proposed 22 Com. Reg. 17229 (May 19, 2000); Amdts Adopted 20 Com. Reg. 15958 (June 15, 1998); Amdts Emergency and Proposed 20 Com. Reg. 15851 (Feb. 15, 1998) (effective for 120 days from Feb. 13, 1998); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). *As of August 31, 2007, a notice of permanent adoption had not been published. *As of December 2005, notices of permanent adoption had not been published. *The February 2010 Notice of Proposed Regulations contained only a summary of the proposals to amend the regulations. It did not contain any actual amendments. See 32 Com. Reg. 30062 (Feb. 19, 2010). Despite this, a Notice of Adoption for these non-existent amendments was published in April of 2010. See 32 Com. Reg. 30092. Commission Comment: PL 1-8, tit. 1, ch. 12, codified as amended at 1 CMC §§ 2601-2633, created the Department of Public Health and Environmental Services within the Commonwealth government. See 1 CMC § 2601. 1 CMC § 2605 directs the Department to adopt rules and regulations regarding those matters over which it has jurisdiction. Executive Order 94-3 (effective August 23, 1994) reorganized the Commonwealth government executive branch, changed agency names and official titles and effected numerous other revisions. According to Executive Order 94-3 § 105: Section 105. Department of Public Health. The Department of Public Health and Environmental Services is re-designated the Department of Public Health. The full text of Executive Order 94-3 is set forth in the commission comment to 1 CMC § 2001. Public Law 16-51 (effective Jan. 15, 2010), the “Commonwealth Healthcare Corporation Act of 2008,” codified at 3 CMC § 2801 et seq., established the Commonwealth Healthcare Corporation, which assumed the duties of the Department of Public Health as of January 15, 2011. PL 16-51 transferred the Medical Referral Program from the Department of Public Health to the Commonwealth Healthcare Corporation. Executive Order No. 2013-09 (effective May 2, 2013) transferred the Medical Referral Program from the Commonwealth Healthcare Corporation to the Office of the Governor. See 35 Com. Reg. 33542. Section 1.1 of the 2013 amended regulations (codified at section 75-50-005) specified that these new regulations were to be codified at subchapter 140-10.7. However, because this office is now under the supervision of the Office of the Governor, the Commission has moved these regulations to Chapter 75-50. © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 2 of 35

TITLE 75: OFFICE OF THE GOVERNOR The March 2016 amendments completely superseded all prior rules and regulations including emergency rules and regulations of the Medical Referral Program. The Commission numbered and renumbered sections and subsections throughout this chapter pursuant to 1 CMC § 3806(a) and rearranged sections to fit harmoniously within this Code pursuant to 1 CMC § 3806(b). The Commission changed capitalization throughout the chapter for the purpose of conformity pursuant to 1 CMC § 3806(f). Part 001 - General Provisions § 75-50-001 Introduction The criteria and procedures established in these rules and regulations for patient medical referrals are designed to provide residents of the CNMI with a means of receiving medical care and treatment not available in the Commonwealth for conditions that are life threatening, constitute a debilitating illness or an acute neurological problem, or may lead to the permanent loss of vision or other function. By sending approved patients established referral health care facilities, they may obtain extended and/or advanced medical care and procedures unavailable in the CNMI. In establishing a Medical Referral Program, it is incumbent upon the CNMI government to manage the program’s operations to ensure that health care benefits afforded to residents of the CNMI are provided in a cost-efficient and equitable manner. It is therefore an objective of these rules and regulations to contain the costs of medical referrals by excluding unnecessary referrals, minimizing inappropriate lengths of stay at referral health care facilities, and establishing cost- sharing mechanisms with patients. The procedures set forth below are essential to the successful operation of a cost-effective health care program. Modified, 1 CMC § 3806(a), (b), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission corrected the capitalization of the words “rules and regulations,” “government,” and “program” pursuant to 1 CMC § 3806(f). In March 2016, the Commission created the part title. § 75-50-005 Medical Referral Services Office There is hereby established a Medical Referral Services Office (“Medical Referral Services” or “MRS”) within the executive branch of the Commonwealth government, which shall facilitate the referral of patients to recognized referral health care facilities outside the CNMI for extended medical care as set forth in these rules and regulations. A list of recognized “referral health care facilities,” as referenced throughout these rules and regulations is included as Appendix A hereto. Other medical facilities may be only considered if a patient is referred to such facilities by a recognized facility or if they specialize in medical care of an approved patient condition. Financial assistance for medical care outside the CNMI, and related costs, shall be available as provided in these rules and regulations to the extent that funds for the program are appropriated by the CNMI legislature. If in any fiscal year, appropriated funding for Medical Referral © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 3 of 35

TITLE 75: OFFICE OF THE GOVERNOR Services is exhausted prior to the end of the fiscal year, Medical Referral Services shall cease operations until additional funding is appropriated or reprogrammed for its operations by the current administration. Modified, 1 CMC § 3806(a), (b), (d), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The 2011 amendments added subsection (a). The Commission inserted a comma after the word “reenacted” in subsection (a) pursuant to 1 CMC § 3806(g). The Commission corrected the capitalization of the words “rules and regulations” and “legislature” in subsection (b) pursuant to 1 CMC § 3806(f). In March 2016, the Commission substituted “Attachment I” with “Appendix A” pursuant to 1 CMC § 3806(d). § 75-50-010 Medical Referral Services Medical Referral Services shall be headed by a Medical Referral Services Director/Administrator appointed by the governor. The duties and responsibilities of Medical Referral Services shall include the following: (a) Assisting patients’ primary care physicians to ensure that all necessary non-medical documentation is included with patients’ petitions for medical referral prior to cases being submitted to the Medical Referral Committee for review. (b) Making all arrangements for patient medical referral including verifying that sufficient funds exist to cover any medical referral costs chargeable to Medical Referral Services, scheduling doctor appointments, and arranging for air and ground transportation and accommodations. (c) Communicating with other CNMI or non-CNMI offices to verify and confirm arrangements for patient arrival at, and/or departure from, the city where the patient’s referral health care facility is located and obtaining continuous updates on the medical status of referral patients. (d) Maintaining records of: the names of patients petitioning for medical referral; the patients’ diagnoses; approved and denied medical referral petitions; the names of any escorts accompanying patients; the names of referral health care facility physicians to whom patients are sent; the treatment to be provided to patients and the costs associated with medical referrals. (e) Maintaining additional patient records, including the following: the number of cases considered for medical referral within each fiscal year; the number of cases approved and disapproved; the medical justification for referrals; the medical justification for denied cases and alternatives offered to the patients; the status of patients sent on medical referral; a financial analysis depicting cost based on the medical treatment provided to patients; a summary of the © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 4 of 35

TITLE 75: OFFICE OF THE GOVERNOR type of cases approved for medical referral and of the treatment and care provided at referral health care facilities. (f) Reviewing medical bills from referral health care facility providers, verifying the validity of medical bills and approving payment of medical bills that are the financial responsibility of Medical Referral Services. (g) Preparing Medical Referral Services’ annual budget for submission to the Office of the Governor. (h) Performing other duties and responsibilities as assigned by the governor. Modified, 1 CMC § 3806(a), (b), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission corrected the phrase “Services budget” in subsection (h) to “Services’ budget” pursuant to 1 CMC § 3806(g). Part 100 - Medical Referral Committee § 75-50-101 Composition There is hereby established a Medical Referral Committee, which shall be composed of six voting members who are physicians licensed by the CNMI Medical Profession Licensing Board. The voting members will be appointed by the CEO of the Commonwealth Health Corporation for a two year term. Any voting member appointed to fill a vacancy will serve for the remainder of the two year term of the voting member he or she is replacing. A minimum of four of the voting members shall be physicians clinically privileged at the Commonwealth Health Center (CHC). The other voting members may be appointed from private clinics. A representative from the following CHC divisions or units and other government agencies shall serve on the Medical Referral Committee, but shall not vote: Social Services; Utilization Review; Medical Referral Services; Medicaid Office and Vocational Rehabilitation Services. Such non-voting members will be appointed by, and serve at the pleasure of, the heads of their respective units. The governor or his designee shall also serve as an ex-officio non-voting member of the Committee. Three voting members must be present to establish a quorum and conduct official business. Modified, 1 CMC § 3806(a), (e), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 5 of 35

TITLE 75: OFFICE OF THE GOVERNOR Commission Comment: In March 2016, the Commission struck the figures “(6)”, “(4)”, and “(3)” as mere repetitions of written words pursuant to 1 CMC § 3806(e). § 75-50-105 Chairperson At the beginning of each fiscal year or as required should the position become vacant, the Medical Referral Committee shall elect a Chairperson from amongst its voting members clinically privileged at CHC. The Chairperson shall serve for a one-year term and may serve multiple successive terms. In the event there is a vacancy in the position, the voting members shall elect a new Chairperson to serve the remainder of the former Chairperson’s one year term. In the event the Chairperson is unable to attend a meeting, any other voting member may fulfill the Chairperson’s duties for that particular meeting with the agreement of a majority of voting members who are present at the meeting. The Chairperson shall schedule regular meetings of the Medical Referral Committee and advise each voting and non-voting member of the date and time of the meeting at least one week prior to its scheduled date. The Chairperson shall also call emergency Medical Referral Committee meetings whenever he or she believes doing so is necessary, or upon the request of a majority of the voting members of the Committee or the governor or governor’s designee. The Chairperson shall be responsible for presiding over all meetings of the Medical Referral Committee and shall rule on all matters of procedure. A procedural decision by the Chairperson may be overruled by a majority of the voting members of the Committee (including the Chairperson himself or herself). Modified, 1 CMC § 3806(a), (f), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission inserted a close parenthesis in the final sentence pursuant to 1 CMC § 3806(g). § 75-50-110 Case Review It shall be the sole responsibility of the Medical Referral Committee to screen and evaluate petitions for medical referral, including requests for additional patient treatment not initially authorized and requests from referral health care facility physicians to refer the patient to a second referral health care facility. After a complete case evaluation, the Medical Referral Committee will determine whether a referral for medical care is warranted. In the event the Medical Referral Committee approves a referral, it shall issue a Medical Treatment Authorization Form, containing the patient’s diagnosis and listing what professional medical services will be authorized for the patient’s referral. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 6 of 35

TITLE 75: OFFICE OF THE GOVERNOR re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). § 75-50-115 Final Decisions Decisions of the Medical Referral Committee shall be final, except as provided in § 75-50-415. This is to ensure that medical referral decisions are only based on patients’ medical conditions. Modified, 1 CMC § 3806(a), (c), (d). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission changed the reference number “Section 6.4 of these Rules and Regulations” to “§ 75-50-415” to agree with the renumbered section pursuant to 1 CMC § 3806(c) and (d). § 75-50-120 Review of Emergency Medical Referral Cases All medical referral cases approved on an emergency basis pursuant to § 75-50-405 shall be reviewed by the Medical Referral Committee at the next regular meeting for assessment of whether the referral was justified. Any referral found to be unjustified by the Medical Referral Committee shall be treated as an unauthorized medical referral and an official notice of the Committee’s decision must be sent to the referring physician. Under such circumstances, the emergency approving authority of the approving MRC voting members may be suspended for up to three months at the discretion of the Committee. Modified, 1 CMC § 3806(a), (c), (d), (e). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission changed the reference number “Section 6.2 of these Rules and Regulations” to “§ 75-50-405” to agree with the renumbered section pursuant to 1 CMC § 3806(c) and (d). The Commission struck the figure “(3)” as a mere repetition of written words pursuant to 1 CMC § 3806(e). § 75-50-125 Modifications to Rules and Regulations Prior to the end of each fiscal year, or sooner if circumstances dictate, the Medical Referral Committee shall submit a list of recommended changes to the Medical Referral Services rules and regulations, if any, to the governor. Modified, 1 CMC § 3806(a), (f), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 7 of 35

TITLE 75: OFFICE OF THE GOVERNOR Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission struck “These” in the section title pursuant to 1 CMC § 3806(g). § 75-50-130 Approval of Reports The Medical Referral Committee shall approve all written and financial reports relating to Medical Referral Services before they are submitted to the governor or the Commonwealth Legislature, when practical. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Part 200 - Program Eligibility § 75-50-201 Introduction For a patient to be eligible for consideration for medical referral through Medical Referral Services each of the following criteria set forth in §§ 75-50-205 and 75-50-210 must be satisfied. Modified, 1 CMC § 3806(a), (b), (c), (d), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission created the section title and changed the final colon to a period pursuant to 1 CMC § 3806(g). The Commission changed the reference numbers “Sections 4.1 and 4.2” to “§§ 75-50-205 and 75-50-210” to agree with the renumbered sections pursuant to 1 CMC § 3806(c) and (d). § 75-50-205 Medical Criteria (a) The patient has a medical condition or conditions that cannot be adequately be treated in the Commonwealth and require that the patient be transferred to a tertiary or other hospital in order to receive a higher level of care. Such conditions include, but are not limited to: acute urgent cardiac conditions, oncology evaluation and treatment, difficulties in access for hemodialysis or peritoneal dialysis including fistula malfunction or acute neurological emergencies, urgent/emergency urological conditions, and urgent pediatric conditions. (b) The patient must be evaluated by a CNMI licensed physician, who is their primary care provider. Medical specialists visiting the CNMI to provide limited term health care services may © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 8 of 35

TITLE 75: OFFICE OF THE GOVERNOR not initiate, but may recommend, a medical referral through the patient’s primary care physician. (c) After a thorough diagnosis of the patient’s case and whether the full utilization of the resources available within the CNMI, including consideration of forthcoming visits by medical specialists, would provide adequate care for the patient, the primary care physician must determine that the health care services required to satisfactorily treat the patient’s illness or condition cannot adequately be provided within the CNMI. (d) The patient’s illness or condition including diagnosis and prognosis must substantiate the need for medical referral. The primary care physician must be prepared to demonstrate to the Medical Referral Committee that medical referral would be likely to significantly benefit the patient’s health outcome. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The 2013 amendments added subsection (a) and re-designated the remaining paragraphs. The Commission inserted a comma after the word “conditions” in subsection (a) pursuant to 1 CMC § 3806(g). In March 2016, the Commission numbered the leading paragraph as subsection (a), and renumbered subsections (a)– (c) to subsections (b)–(d) pursuant to 1 CMC § 3806(a). § 75-50-210 Residency Criteria (a) The patient must be a United States citizen or a green card holder residing in the CNMI, the immediate relative of a U.S. citizen, or another individual who has established legal permanent residence in the CNMI as defined by federal immigration law, including, but not limited to, United States nationals. (b) For purposes of these rules and regulations, “residence” shall mean “the place where a person maintains an abode with the intention of remaining permanently or for an indefinite period of time legally.” It shall be the responsibility of the patient or the patient’s representative to demonstrate residence in the CNMI to the satisfaction of the Medical Referral Services staff. In determining the residence of a patient, the Medical Referral Services staff shall consider the patient’s overall situation in the CNMI, including the following, if applicable: (1) Proof of the patient’s citizenship and immigration status (e.g., birth certificate, passport, green card, permanent residence card, marriage or adoption certificate, social security card); (2) the patient’s country of origin and the number of days the patient spends in the CNMI each year; (3) the patient’s CNMI employment history; (4) whether the patient is enrolled in a CNMI school, college, or other educational institution; (5) whether the patient possesses a valid CNMI driver’s license; (6) whether the patient is a registered voter in the CNMI; © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 9 of 35

TITLE 75: OFFICE OF THE GOVERNOR (7) whether the patient has public utilities billings under his or her name in the CNMI; (8) whether the patient has a CNMI postal address; (9) whether the patient has made tax filings in the CNMI; (10) the patient’s enrollment in CNMI assistance programs such as Medicaid, WIC, food stamps, or Low Income Housing Energy Assistance; and (11) any other documents indicative of permanent residence in the CNMI. Modified, 1 CMC § 3806(a), (f), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Amdts Emergency and Proposed 27 Com. Reg. 24705 (Aug. 22, 2005) (effective for 120 days from Aug. 19, 2005); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission inserted semicolons at the ends of subsections (b)(5) and (b)(6) and a period at the end of subsection (b)(10) pursuant to 1 CMC § 3806(g). In March 2016, the Commission renumbered subsections (b)(i)–(xi) to subsections (b)(1)–(11) respectively pursuant to 1 CMC § 3806(a). The Commission changed the colon after “e.g.” in subsection (b)(1) to a comma pursuant to 1 CMC § 3806(g). § 75-50-215 Persons Ineligible for Participation in the Program The following categories of persons are ineligible for participation in the Medical Referral Program: (a) Common-law spouses of United States citizens; (b) United States citizens who are not permanent residents of the CNMI; (c) CNMI residents studying abroad; (d) CNMI residents living abroad or in another area of the United States; (e) CNMI residents who are traveling abroad; (f) residents of the CNMI and/or their dependents who exercise their right to obtain medical care outside the CNMI government health care system and obtain medical care which has not been previously authorized by the Medical Referral Committee; and (g) persons who have entered the CNMI or are present in the CNMI in violation of United States immigration laws. Modified, 1 CMC § 3806(a), (f), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 10 of 35

TITLE 75: OFFICE OF THE GOVERNOR re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Amdts Emergency and Proposed 27 Com. Reg. 24705 (Aug. 22, 2005) (effective for 120 days from Aug. 19, 2005); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission struck the colon in the section title pursuant to 1 CMC § 3806(g). Part 300 - The Medical Referral Program Covered Benefits § 75-50-301 Introduction Subject to the payment guidelines set forth in part 700 of this chapter, Medical Referral Services provides the following medical, ancillary, transportation, escort, and maintenance benefits for patients authorized for medical referral. Modified, 1 CMC § 3806(a), (c), (d), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission created the section title and changed the final colon to a period pursuant to 1 CMC § 3806(g). The Commission changed the reference number “Section 11 of these Rules and Regulations” to “part 700 of this chapter” to agree with the renumbered sections pursuant to 1 CMC § 3806(c) and (d). § 75-50-305 Medical Costs (a) Inpatient Medical Care. Inpatient medical care at a referral healthcare facility for the following health care services: (1) necessary admission to special units such as intensive care coronary care; (2) necessary admissions to the operating room and recovery room; (3) anesthesia services; (4) x-rays, radiology services, and other such investigatory services; (5) radiation, chemo, physical, occupational, and speech therapy; (6) normal blood transfusions; (7) laboratory tests; (8) regular nursing care services; (9) prescribed rehabilitative therapy; (10) medical supplies such as casts, surgical dressings, and splints; (11) drugs furnished by the health care facility during the hospital stay; (12) use of appliances and/or equipment such as wheelchairs; (13) A semiprivate room (2 to 4 beds to a room) or a non-private room (more than 4 beds to a room); (14) all hospital meals, including those which require special preparation for particular diets. (b) Outpatient Care. Outpatient medical care at a referral health care facility for the following health care services: © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 11 of 35

TITLE 75: OFFICE OF THE GOVERNOR (1) services in an emergency room or outpatient clinic, including ambulatory and surgical procedures; (2) normal blood transfusions furnished to the patient on an out-patient basis; (3) laboratory tests; (4) x-rays, radiology services, and other such investigatory services; (5) radiation, chemo, physical, occupational, and speech therapy; (6) medical supplies such as casts, surgical dressings, and splints; (7) drugs and biological products which cannot be self-administered. (c) Professional Fees. Fees for professional health care services specifically authorized by the Medical Referral Committee in the Medical Treatment Authorization Form. Professional fees for health care services beyond those approved by the Medical Referral Committee, or for health care services of medical specialists not related to the original diagnosis in the Medical Treatment Authorization Form are not covered by Medical Referral Services unless authorized by the Director after consultation with at least two voting members of the Medical Referral Committee, or authorized by at least two voting members of the Medical Referral Committee independently of the Director, prior to the rendering of such additional health care services in non-emergency situations. Modified, 1 CMC § 3806(a), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission inserted a comma after the word “services” in subsection (b)(4), converted a comma in subsection (b)(7) to a period, and corrected the spelling of the word “fees” in subsection (c) pursuant to 1 CMC § 3806(g). The Commission inserted commas after the words “occupational” in subsection (a)(5), “dressings” in subsection (a)(10), “services” in subsection (b)(4), and “occupational” in subsection (b)(5). In March 2016, the Commission renumbered subsections (a)(i)–(xiv) to subsections (a)(1)–(14) and subsections (b)(i)–(vii) to (b)(1)–(7) pursuant to 1 CMC § 3806(a). The Commission struck the period in the section title and inserted a comma after “radiology services” in subsection (b)(4) pursuant to 1 CMC § 3806(g). § 75-50-310 Ancillary Costs (a) Prescribed Drugs. Drugs prescribed for the cure, mitigation, or prevention of disease, or for health maintenance, if: (1) prescribed in writing by a licensed referral health care facility physician, or other referral health care facility licensed practitioner authorized to prescribe drugs under state, territorial, or relevant national law; (2) dispensed by a licensed pharmacist or licensed practitioner authorized to dispense drugs who records and maintains the patient’s written prescription in the pharmacy’s records; and (3) they cannot be dispensed without a prescription (i.e., over-the-counter drugs are excluded). (b) Durable medical equipment provided by the referral health care facility that is essential © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 12 of 35

TITLE 75: OFFICE OF THE GOVERNOR for the management of the patient’s condition during transfer back to the CNMI. Examples of durable medical equipment covered by this subsection include portable oxygen equipment, cardiac monitoring equipment, and mechanical ventilators. Such durable medical equipment provided to patients under Medical Referral Services shall become the property of Medical Referral Services and must be turned over by the patient after it is no longer needed. Patients who fail to give Medical Referral Services any durable medical equipment provided to them by the referral health care facility after they are no longer required, shall be charged the replacement cost of the equipment. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission inserted a comma after the word “equipment” in subsection (b) pursuant to 1 CMC § 3806(g). In March 2016, the Commission renumbered subsections (a)(i)–(iii) to subsections (a)(1)–(3) pursuant to 1 CMC § 3806(a). § 75-50-315 Transportation Costs (a) Air Transportation. (1) Medical Referral Services assists with the least expensive round trip air transportation available on regular commercial airlines (considering the patient’s medical condition for travel) to the referral recognized health care facility as follows: (i) if a patient has an individual income over $50,000perannumorthepatient’sjointhouseholdincomeexceeds$75,000, the patient must pay 100% of the air transportation cost; (ii) if a patient has an individual income between $25,000–$50,000 per annum or the patient’s joint household income is between $37,500–$62,500, the patient pays 50% and MRS pays 50% of the air transportation cost; (iii) if a patient individually earns below $25,000 per annum or the patient’s family unit is falls under the indigent level, MRS pays 100% of the air transportation cost. (b) Medical Referral Services shall only be responsible for air transportation up to the actual cost or the equivalent cost for a medical referral to the State of Hawaii, whichever is lower. (c) Air transportation costs for Medicare and Pediatric Medicaid patients are covered up to the costs of transportation to the States of Washington, Oregon, and California. (d) Ambulance Transportation. The cost of medically necessary ambulance transportation for medical referral patient from the Commonwealth Health Center to Saipan International Airport, from the designated international airport near where the referral health care facility is located to the referral health care facility, transportation to other health care facilities for special treatment not available at the designated health care facility, and transportation as otherwise approved by the Medical Referral Committee. © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 13 of 35

TITLE 75: OFFICE OF THE GOVERNOR Modified, 1 CMC § 3806(a), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The paragraphs of subsection (a) were undesignated in the original regulation. The Commission designated them as subsections (a)(1) and (a)(2) pursuant to 1 CMC § 3806(a). The Commission corrected the capitalization of the words at the beginning of subsections (a)(1)(i) through (a)(1)(iii) pursuant to 1 CMC § 3806(f). The Commission corrected a semicolon at the end of subsection (a)(1)(iii) to a period pursuant to 1 CMC § 3806(g). In March 2016, the Commission renumbered subsections (a)(i)–(iii) to subsections (a)(1)(i)–(iii); numbered the unnumbered paragraphs following subsection (a)(iii) as subsections (b) and (c); and renumbered subsection (b) to subsection (d) pursuant to 1 CMC § 3806(a). The Commission changed “$37,50”insubsection(a)(1)(ii)to“$37,500” and changed a semicolon to a comma in subsection (d) pursuant to 1 CMC § 3806(g). § 75-50-320 Patient Escorts Medical personnel and/or one family member or close friend to serve as a patient escort in the following situations, as authorized by the Medical Referral Committee: (a) The Medical Referral Committee, in consultation with the patient’s primary care physician, shall determine whether it is necessary for a physician escort, registered nurse escort, respiratory therapist escort or a combination of such escorts (including multiple escorts of the same type), to accompany the patient to the referral health care facility to ensure adequate medical care while in transit. The following guidelines shall be considered by the Medical Referral Committee in deciding whether a medical escort is needed: (1) Physician Escorts. A physician escort should accompany a medical referral patient whenever there is a high likelihood that the patient’s medical condition could change during the transport and it may be necessary for the physician to make a diagnosis, stabilize the patient, and/or provide acute treatment for the patient. (2) Nurse Escorts. Any medical referral that has been approved by the Medical Referral Committee and that requires a nurse escort must utilize a registered nurse who holds a current Advanced Cardiac Life Support (ACLS) certification. Patients requiring medical referrals and a nurse escort are in a medically compromised state and must be escorted by nurses capable of handling their medical needs as apparent at the time of transport. These medical needs may include the insertion of an intravenous line, the addition of medication to an intravenous line, and the administration of narcotics. Per CHC’s position descriptions, only registered nurses can perform the aforementioned functions. ACLS certification is required so that, in the event of an emergency, the nurse escort can provide care to any patient experiencing cardiac arrest. (3) Respiratory Therapist Escort. A respiratory therapist escort should accompany a medical referral patient whenever the patient will require respiratory therapist services (e.g., a patient in respiratory failure who requires a ventilator or other breathing assistance), and the patient is stable and his or her medical condition is unlikely to change. (4) The Director of Medical Affairs, in consultation with the patient’s primary care physician © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 14 of 35

TITLE 75: OFFICE OF THE GOVERNOR and the appropriate nurse and/or respiratory therapist supervisor(s), shall decide which members of the Commonwealth Health Center medical staff, nursing staff, and/or respiratory therapist staff shall accompany the patient. In those cases where a physician, nurse, and/or respiratory therapist escort accompany the patient, it will be such escort’s responsibility to: (i) assist and attend to the patient during the flight; (ii) ensure that the patient’s medical documents are turned over to the appropriate personnel from the referral health care facility; and (iii) ensure that all medical instruments, pillows, sheets, and other hospital supplies used during the medical transport are accounted for and returned to CHC and/or MRS (5) Transportation Fees for Physician, Nurse, and Respiratory Therapist Escorts. In addition to the cost of airline tickets, physician, nurse, and/or respiratory therapist escorts accompanying the patient on the medical referral shall each be entitled to receive a lump sum transport fee, in lieu of a per diem allotment, for the first 24 hours of travel, based on the location to which the patient is being medically referred. The transport fee, which is intended to cover payment for any hotel accommodations and food required by the physician, nurse and/or respiratory therapist escorts during the transport, shall be based on the following schedule: (i) Guam $175.00†(ii)Philippines$200.00† (iii) Hawaii $250.00†(iv)Japan$275.00† †Same fees if originating from above destinations to CNMI. (6) If, because of unavailability of seats on the airline, the physician, nurse and/or respiratory therapist escorts are unable to return to the CNMI within a 24 hour period, they shall then be entitled to receive the standard government per diem allotment for any portion of a day following the first 24 hours of travel. (b) Family or Friend Escorts. (1) Medical Referral Services will pay the least expensive round trip air transportation available on regular commercial airlines for a family or friend escort as described in this section if the patient or intended escort has an annual income of less than $70,000. Such assistance will be used for: the family or friend escort to reach the patient’s designated destination for the purpose of meeting and accompanying the patient; medically necessary ambulance transportation in which the family or friend escort accompanies the patient; and/or accommodations for one family or friend escort. A family or friend escort may be a family member or close friend of the patient, as provided by these rules and regulations. Unless specifically determined by the Medical Referral Committee to be unnecessary considering the limited resources available for other patients, the Medical Referral Committee must approve for each non-active medical referral patient a medically, physically and mentally fit family or friend escort for the patient in such cases where the patient is unable to travel independently because of: (i) physical disability, frailty, status as a minor, or age; (ii) psychiatric disability or mental deficiency; (iii) full or partial blindness or deafness; (iv) potential or actual language barriers; (v) fecal or urinary incontinence requiring assistance for the patient to use the toilet; (vi) the patient’s inability to feed himself or herself or to perform other activities required for daily living; or © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 15 of 35

TITLE 75: OFFICE OF THE GOVERNOR (vii) a strong possibility that the patient will die at the referral health care facility as a result of the severity of the illness or condition; (viii) admittance as an inpatient who will be undergoing major surgery involving general anesthesia. (2) It is the prime responsibility of the family or friend escort to assist, monitor and represent the patient at all times, if patient is medically or mentally incapable of making sound and proper judgments. A family or friend escort shall not accept or be burdened with other responsibilities for the duration of the patient’s referral, but may request to be relieved of service if a new escort may be put into place. Non-compliant or relieved family or friend escorts will be replaced at the patient’s expense (the patient will pay for the replacement’s airfare). The non-compliant or relieved family or friend escort must pay for all expenses for their return to the CNMI. Family or friend escorts must agree and acknowledge the above responsibilities that apply for the duration of the referred patient’s medical treatment and care. (3) Active medical referral patients are not eligible to a family or friend escort unless declared medically (physically and mentally) fit by a licensed physician and approved by the Medical Referral Committee. Patients are not entitled to financial assistance for a family or friend escort if the patient’s or intended escort’s income was more than $70,000 in the twelve months immediately preceding the date of approval for medical referral. Modified, 1 CMC § 3806(a), (e), (f), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Amdts Adopted 24 Com. Reg. 19032 (Feb. 28, 2002); Amdts Proposed 23 Com. Reg. 18351 (Sept. 24, 2001); Amdts Adopted 22 Com. Reg. 17349 (July 20, 2000); Amdts Proposed 22 Com. Reg. 17229 (May 19, 2000); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The 2000 amendments added new subsection (a)(5). The 2002 amendments added a new subsection (b)(1)(vii) and amended the opening paragraph of subsection (b)(1). The 2013 amendments amended subsection (b) and added subsections (c) and (d). The Commission substituted section numbers pursuant to 1 CMC § 3806(d). The original paragraphs of subsection (b)(2) were undesignated. The Commission designated them as subsections (b)(2)(i) and (b)(2)(ii) pursuant to 1 CMC § 3806(a). The Commission inserted commas after the words “nurse” in subsections (a) and (a)(5), “staff” in subsection (a)(4), and “physically” in subsection (b)(2)(i) and an apostrophe into the word “patient’s” in subsection (b)(2)(i)(e) pursuant to 1 CMC § 3806(g). The Commission corrected the capitalization of the words “one hundred” in subsection (b)(1) and the words at the beginning of subsections (b)(2)(i)(A) through (b)(2)(i)(E) and (b)(2)(i)(A) through (b)(2)(i)(B) pursuant to 1 CMC § 3806(f). The Commission corrected the punctuation at the ends of subsections (b)(2)(i)(A) through (b)(2)(i)(E) and (b)(2)(i)(A) through (b)(2)(i)(B) pursuant to 1 CMC § 3806(g). The Commission struck the figures “100%” from subsection (b)(1) and “12” from subsection (d) pursuant to 1 CMC § 3806(e). In March 2016, the Commission renumbered this section, numbered its unnumbered paragraphs, and renumbered its subsections pursuant to 1 CMC § 3806(a). The Commission changed “ * ” in subsections (a)(5)(i)–(iv) to “ † ” pursuant to 1 CMC 3806(g). The Commission struck the figure “(12)” in subsection (b)(3) as a mere repetition of written words pursuant to 1 CMC § 3806(e). § 75-50-325 Maintenance Costs © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 16 of 35

TITLE 75: OFFICE OF THE GOVERNOR (a) Accommodations, ground transportation, and subsistence allowance as follows, if eligible (not to exceed the equivalent value of such referral costs to the State of Hawaii or actual costs, whichever is less); (1) In-Patient Referrals. Room and board for in-patients provided through the referral health care facility. (2) Out-Patient Referrals. Out-patients on medical referral shall receive reasonable accommodations not to exceed the contracted rate for the State of Hawaii. Out-patients shall also be provided ground transportation not to exceed $10.00perdayofeachmedicalappointment,wherethereisnoactualcitypublictransportationandgroundtransportationisnotprovidedbytheCNMIgovernment,aswellasasubsistenceallowancenottoexceed$30.00 per day depending on medical facility location. (3) Patient Escorts. Authorized family or friend escorts shall receive reasonable accommodations at Medical Referral Services’ expense. The family or friend escort shall share a room with the medical referral patient. The family or friend escort will be provided daily ground transportation allowance not to exceed $10.00perdaydependingonactualdistancetothemedicalfacility,iftheirroomaccommodationlocationisoutsidethemedicalfacility,andonlyifnocitypublictransportisavailableandnogroundtransportationisprovidedbytheCNMIgovernment.Thefamilyorfriendescortwilladditionallyreceiveasubsistenceallowancenottoexceed$30.00 per day depending on medical facility location. (b) Right To Refuse Government Room and Board. Medical referral patients and authorized family or friend escorts have the right to refuse accommodations arranged by Medical Referral Services. However, if a patient and/or family or friend escort make independent arrangements for accommodations, Medical Referral Services shall not be liable for any expenses incurred with respect to such accommodations. Modified, 1 CMC § 3806(a), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016);Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Amdts Adopted 29 Com. Reg. 26511 (Apr 16, 2007); Amdts Proposed 28 Com. Reg. 26210 (Oct. 30, 2006); Amdts Emergency and Proposed 28 Com. Reg. 26308 (Nov. 30, 2006) (effective for 120 days from November 13, 2006); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: On September 21, 2004, the Department of Public Health promulgated emergency and proposed amendments that added a new section 5.6 regarding airfare benefits. See 26 Com. Reg. 22836 (Sept. 24, 2004) (effective for 120 days from Sept. 21, 2004). As of December 2004, a notice of permanent adoption had not been published. On August 22, 2005, the Department of Public Health promulgated emergency and proposed amendments that added a new section 5.6, entitled “Repayable Financial Assistance in the Form of an Accommodations Allowance for an Immediate Relative of a Patient with Catastrophic Illness.” See 27 Com. Reg. 24705 (Aug. 22, 2005) (effective for 120 days from Aug. 19, 2005). As of December 2005, a notice of adoption had not been published. If adopted, this section will be codified at § 75-50- 330. In November 2006, emergency amendments were promulgated for subsection (a)(1) that removed the twenty dollars per day subsistence allowance from subsections (a)(1)(ii) and (a)(1)(iii). These amendments were effective for 120 days from November 13, 2006. As of August 2007, a notice of permanent adoption had not been published for the November 2006 amendments. In April 2007, subsection (a)(2) was repealed. © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 17 of 35

TITLE 75: OFFICE OF THE GOVERNOR In March 2016, the Commission renumbered subsections (a)(i)–(iii) to subsections (a)(1)–(3) pursuant to 1 CMC § 3806(a) Part 400 - Procedures for Medical Referral § 75-50-401 Non-Emergency Referral Cases The procedures for all non-emergency patient cases that may be appropriate for medical referral shall be as follows: (a) Physician Assessment. Once the patient’s primary care physician has made a thorough evaluation of the patient’s illness and/or medical condition and determined that the patient satisfies the medical criteria for medical referral as provided in § 75-50-205, the primary care physician shall discuss the patient’s case with the chairperson of the applicable CHC medical department (or, if the primary care physician is the chairperson, then with another physician in the applicable medical department) to obtain a second opinion on whether the patient’s case is appropriate for a petition for medical referral. If both physicians agree that the patient’s case should be forwarded to the Medical Referral Committee, the primary care physician shall contact the appropriate physician specialist at a referral health care facility to discuss the patient’s case and to assess the appropriateness of the treatment available at such facility. (b) Medical Referral Documentation. If, after a complete assessment of the patient’s case as specified above in subsection (a), the primary care physician determines that the patient’s case is appropriate for a petition for medical referral, the primary care physician shall confirm with the Medical Referral Services staff that the patient satisfies the eligibility criteria for medical referral set forth in § 75-50-210. If the patient is found to be eligible, the primary care physician shall obtain and attach any relevant laboratory and/or radiology reports, and complete the required forms below and other applicable requirement listed on the medical referral checklist attached to the referral package: (1) Patient Referral Records (2) Air Travel Medical Form (must be signed by patient) (3) Patient’s History and Referral Note (c) The primary care physician shall make sure all forms listed above are properly completed with all required signatures, notes are transcribed and signed, other supporting reports, insurance, and patient contact information, films and test results are attached before submitting to Medical Referral Services. Medical Referral Services will return any improperly filled or incomplete referral packages to the referring physician for correction and/or proper completion. No action can be taken until a properly completed application package is submitted. (d) Case Presentation. The primary care physician shall present the patient’s case to the Medical Referral Committee at the next regular Committee meeting. It shall be the responsibility of the primary care physician to present the prepared documentation, describe the patient’s illness or medical condition, explain why medical referral is appropriate, and answer any questions raised by the Medical Referral Committee. The Committee may elect not to review any scheduled cases without the referring physician being present. © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 18 of 35

TITLE 75: OFFICE OF THE GOVERNOR (e) Medical Referral Committee Determination. The Medical Referral Committee shall consider the primary care physician’s presentation, review the documentation, assess whether the patient’s condition can be adequately treated with the resources available within the Commonwealth and decide whether medical referral of the patient is warranted. The decision of the Medical Referral Committee shall be final, except as provided in § 75-50-415. The Director shall promptly advise the primary care physician of the Medical Referral Committee’s decision. The Director shall subsequently send written notice of the Committee’s decision to the primary care physician for discussion with the patient. (f) Medical Referral Arrangements. If medical referral is approved, the primary care physician shall provide the Medical Referral Services staff with the time frame and method for transferring the patient to the referral health care facility. Medical Referral Services, in coordination with other relevant entities, shall make all medical, travel, and accommodation arrangements in the city where the referral health care facility is located. The patient must have a confirmed appointment with a physician at the referral healthcare facility prior to departing the Commonwealth. Self-arranged referrals by approved medical referral patients in accordance with the Committee’s approved conditions are eligible for reimbursement of standard referral benefits upon submission of all original supporting documents to Medical Referral Services. (g) Execution of Medical Referral Authorization Documentation. If the patient’s case is approved for medical referral, two voting members of the Medical Referral Committee must sign a Patient Referral Record. After all arrangements are completed and confirmed, a Medical Treatment Authorization Form must be completed, signed by the case worker, and forwarded for approval by the Director before the patient departs. Review by the Director is limited to compliance with procedures and policies. (h) Documents To Be Prepared by Patient. Prior to the patient’s departure from the Commonwealth, the Medical Referral Services staff shall require the patient, or patient’s representative, to complete or sign the following forms, if applicable: (1) Release(s) of Liability (2) Medical Treatment Authorization (3) Promissory Note (4) Subrogation of Claims Form (see § 75-50-701) (5) Power of Attorney (when appropriate) (6) Affidavit by Recipient of Assistance (7) Indigent Medical Assistance Application (8) Authorization for Release of Medical Records (9) Indigent Eligibility Certification Modified, 1 CMC § 3806(a), (c), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The original paragraphs of subsection (b) were not designated. The Commission designated © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 19 of 35

TITLE 75: OFFICE OF THE GOVERNOR subsections (b)(1) and (b)(2). The Commission inserted the final periods in subsections (a)(1)(iv) and (g)(5). The Commission inserted a comma after the word “worker” in subsection (f) pursuant to 1 CMC § 3806(g). In March 2016, the Commission renumbered this section, numbered its unnumbered paragraphs, and renumbered its subsections pursuant to 1 CMC § 3806(a). The Commission changed the reference numbers “Section 4.1 of these Rules and Regulations” in subsection (a) to “§ 75-50-205”; “Section 6.1.a” in subsection (b) to “subsection (a)”; “Section 4.2 of these Rules and Regulations” in subsection (b) to “§ 75-50-210”; “Section 6.4” in subsection (e) to “§ 75-50-415”; and “Section 11.1” in subsection (h)(4) to “§ 75-50-701” to agree with renumbered sections and subsections pursuant to 1 CMC § 3806(c). § 75-50-405 Emergency Referral Procedures In cases where a primary care physician determines that a patient is in a critical or otherwise urgently life-threatening medical condition and must receive emergency medical care that cannot be adequately provided in the Commonwealth, thereby justifying immediate evacuation of the patient to an off-island referral health care facility, the following procedures shall be followed: (a) Expedited Approval. The patient’s primary care physician, after consultation and obtaining the approval of two of the voting Medical Referral Committee members, may refer the patient without the case being reviewed by the full Committee. One of the two approving Medical Referral Committee members must notify Medical Referral Services of the emergency situation to allow MRS to coordinate the referral with the patient’s primary care physician and other necessary parties. (b) Notice to Referral Health Care Facility. The primary care physician shall contact the appropriate physician specialist or another available physician at the referral health care facility to report the imminent patient referral and to discuss the clinical details of the patient’s case. When required, the primary physician must also coordinate with Medical Referral Services staff to obtain administrative approval by the referral health care facility. (c) Medical Referral Documentation. The primary care physician shall complete and sign all required forms and attach all necessary supporting documents such as films, lab reports, and other items as set forth in § 75-50-401(b). If the patient is unable to sign where a patient’s signature is required, a legal representative may sign for the patient. If the patient has no legal representative, the primary care physician may sign for the patient. Any signature other than the patient’s requires the following to be written next to the signature: the printed name of the person signing; a notation of the signer’s relationship to the patient; and a description of the basis for the signer’s authority to sign on the patient’s behalf. (d) Medical Referral Arrangements. Medical Referral Services staff shall immediately contact a commercial airline or a travel agency to make the referral patient’s travel arrangements. Copies of the Medical Referral Services travel request and travel authorization shall be delivered to the commercial airline or travel agency as soon as possible. Medical Referral Services staff shall send a travel advisory to the medical referral services coordinator or representatives and official providers in the city where the referral health care facility is located. This document shall include the following: the patient’s name, sex, age, diagnosis, flight number, estimated time of © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 20 of 35

TITLE 75: OFFICE OF THE GOVERNOR arrival, and whether an ambulance, stretcher, and/or other supportive devices will be required upon arrival. The names of any physician, nurse, or respiratory therapist and/or family or friend escorts must also be included on the travel advisory. (e) Funding Approval. Travel authorizations for patient emergency medical referral during non-working hours shall be executed by the MRS Director the next business day following the emergency medical referral. (f) Medical Evacuation. If an emergency medical referral is necessary and commercial airline transportation is unavailable, the Medical Referral Services Director or his or her designee may exercise discretion on contacting any of the United States Armed and/or Uniformed Services on the Territory of Guam or the State of Hawaii to seek their assistance in evacuating the patient. However, before contacting any of the Armed or Uniformed Services, the Medical Referral Director or designee must ensure that: (1) the medical case involves an immediate life-threatening situation; and (2) there will be no commercial flight available for transport in the time period specified by the primary care physician for medical referral. (g) Once the Medical Referral Services Director or his or her designee contacts one of the components of the Uniformed Services requesting assistance on a medical referral case, the primary care physician must be available to provide the appropriate officers and other members of the Uniformed Services contacted with the details of the medical case and the requirements for the evacuation. The Medical Referral Services Director or designee shall, if warranted, advise the governor on the details of the emergency medical evacuation case at the earliest reasonable time. Modified, 1 CMC § 3806(a), (c), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The original paragraphs of subsection (f) were not designated. The Commission designated subsections (f)(1) through (f)(3). In March 2016, the Commission renumbered subsections (f)(i)–(ii) to subsections (f)(1)–(2), and numbered the last paragraph as subsection (g) pursuant to 1 CMC § 3806(a). The Commission changed the reference number “Section 6.1(b)” in subsection (c) to “§ 75-50-401(b)” to agree with renumbered sections pursuant to 1 CMC § 3806(c). The Commission struck “that” in subsection (f)(2) as a mere repetition of written words pursuant to 1 CMC § 3806(e). § 75-50-410 Approval for All Medical Referrals All medical referrals to health care facilities outside the CNMI must receive prior approval from the Medical Referral Committee. An otherwise eligible person who is already receiving medical care at a Medical Referral Services approved facility/provider will not be disqualified from prospective or future medical referral benefits simply because he or she does not return to Saipan first. Instead, the Medical Referral Committee will evaluate a patient’s request as to prospective © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 21 of 35

TITLE 75: OFFICE OF THE GOVERNOR or future benefits only. Benefits will not be paid retroactively, i.e. for periods of time prior to application and Medical Referral Committee approval. No other eligibility or Medical Referral Services requirements are affected by this section. Prospective or future limited accommodation benefits may be authorized for self-referred patients who otherwise would be eligible for assistance by Medical Referral Services. The medical care to be delivered must meet all other medical referral standards, including, but not limited to, the requirement that the medical care needed cannot be provided in the CNMI. A patient already on medical referral at a referral health facility may not be transferred to a second referral health care facility without the express authorization of the Medical Referral Committee, except in cases of emergency. In all cases, the attending physician at the approved referral center/provider must communicate directly with the patient’s CNMI primary care physician. Modified, 1 CMC § 3806(a), (d). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Amdts Adopted 26 Com. Reg. 22867 (July 26, 2004); Amdts Emergency and Proposed 26 Com. Reg. 22500 (May 24, 2004) (effective for 120 days from Apr. 27, 2004); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission substituted “this provision of the regulations” in the fourth sentence with “this section” pursuant to 1 CMC § 3806(d). § 75-50-415 Denial of a Presented Referral Case If a patient’s medical referral petition is denied by the Medical Referral Committee, the Medical Referral Director shall inform the primary care physician of the Committee’s decision in writing. If the referring physician is not satisfied with the Committee’s decision, he or she may submit the patient’s case for reconsideration at the next Committee meeting, provided additional facts are added for discussion. Modified, 1 CMC § 3806(a), (d). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); History: Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Part 500 - Emergency Transfers from Rota § 75-50-501 Emergency Evacuation Notwithstanding § 75-50-410, and because of Rota’s proximity to the Territory of Guam, Rota’s resident physician, after consultation with CHC Emergency Department, may request that medical emergency patients from Rota be evacuated directly to a Guam referral health care facility after getting the approval of one voting member of the Medical Referral Committee. © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 22 of 35

TITLE 75: OFFICE OF THE GOVERNOR Such approval shall be determined by whether the required medical services can be provided at the Commonwealth Health Center. The Rota resident physician must coordinate with a receiving physician at the referral facility regarding the patient’s clinical information. The Rota resident physician must also fax or email completed required referral documents to the Medical Referral Services Saipan office. The approving Medical Referral Committee member must notify a member of the Medical Referral Services staff or the Director of the emergency situation, so that they may coordinate the referral with the counterpart to MRS on Guam and the Rota resident physician. Modified, 1 CMC § 3806(a), (c), (d), (e). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission substituted section numbers pursuant to 1 CMC § 3806(d). In March 2016, the Commission substituted “Section 6.3 of these Rules and Regulations” in with “§ 75-50-410” pursuant to 1 CMC § 3806(c) and (d). The Commission struck the figure “(1)” as a mere repetition of written words pursuant to 1 CMC § 3806(e). § 75-50-505 Authority to Transfer Aside from the Rota resident physician, only a CNMI licensed physician, or in the absence of a CNMI licensed physician, another licensed medical professional authorized by the Resident Director of the Rota Health Center can make medical transfer decisions after consultation with the CHC Emergency Department. No other individual, regardless of office or title, may authorize the transfer of a patient from Rota. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). § 75-50-510 Responsibility for Payment of Medical Care Residents of Rota, Tinian, Saipan, and the Northern Islands are equally responsible for the payment of medical bills they incur for medical services rendered to them. All medical bills incurred while a patient is at a referred emergency facility on Guam that are not covered by health care financial support or a third-party payer, are the financial responsibility of the patient. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 23 of 35

TITLE 75: OFFICE OF THE GOVERNOR re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Part 600 - Follow-up; Exclusions; Emergencies § 75-50-601 Follow-up Medical Appointments (a) Medical referral patients are not automatically entitled to a follow-up medical appointment at a referral health care facility. Patient petitions for follow-up appointments shall be treated in the same manner as initial petitions for medical referral, and shall be subject to the same standards and procedures as initial medical referrals. (b) Patients may be allowed one follow up after medical procedures or completion of treatment upon the Committee’s review and approval of new petition with updated medical information. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission numbered the paragraphs pursuant to 1 CMC § 3806(a). § 75-50-605 Medical Referral Program Exclusions The following charges shall be excluded from coverage under the Medical Referral Program, and shall be the financial responsibility of the patient, unless the Committee confirms the medical condition of the patient is severe and life threatening: (a) Any charges related to medical treatment or care that could have been adequately provided at the Commonwealth Health Center. (b) Any charges for occupational diseases or injury that are covered by worker’s compensation benefits. (c) Any charges incurred at a Veterans Administration facility. (d) Any charges related to health care services provided by a government-funded public health program. (e) Any charges incurred for personal comfort items or medically unnecessary upgrades, including telephone, radios, private housing accommodations, movie and car rentals, hospital room or amenities upgrades, and special order meals. (f) Any charges related to nursing home-type care provided by an institution not qualified as © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 24 of 35

TITLE 75: OFFICE OF THE GOVERNOR a hospital under federal, state, or territorial law. (g) Any charges related to cosmetic surgery, except as required for repair of catastrophic injury or congenital malformation. (h) All medical charges related to organ or bone marrow transplant surgery (with or without stem cells). MRS may only assist with maintenance costs in such circumstances if block rooms and ground transportation are available at the referred location. (i) Orthopedic procedures including bone extension or other elective procedures. Exceptions may be made at the Medical Referral Committee’s discretion. (j) Dermatology, rheumatology, and endocrinology evaluation and consultation. Exceptions may be made at the Medical Referral Committee’s discretion. (k) Any charges relating to a patient obtaining a second opinion on a recommended treatment or procedure. (l) Any charges relating to medical treatment rendered for investigatory or experimental purposes, or medical treatment for which there is no established benefit to the patient’s health. (m) Any charges for medical care not authorized by the Medical Referral Committee or charges for medical care provided by a facility or provider other than a recognized referral health care facility or recognized provider. (n) Any charges related to tertiary, palliative care or services that may be identified by the Medical Referral Committee as so expensive as to impact the overall financial integrity of Medical Referral Services. (o) Any charges in excess of the lifetime limit specified in § 75-50-715. (p) Any charges for treatment for persons who refused treatment during a prior referral for the same medical diagnosis. Exceptions may be made at the Medical Referral Committee’s discretion. Modified, 1 CMC § 3806(a), (b), (c). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission corrected the capitalization of the words “rheumatology” and “endocrinology” in subsection (j) pursuant to 1 CMC § 3806(f). The Commission inserted a comma after the word “extension” in subsection (i) and a period at the end of subsection (i) pursuant to 1 CMC § 3806(g). In March 2016, the Commission substituted “Section 11.4” in subsection (o) with “§ 75-50-715” pursuant to 1 CMC § 3806(c). © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 25 of 35

TITLE 75: OFFICE OF THE GOVERNOR § 75-50-610 Humanitarian and Emergency Provisions In the event a person who would be ineligible for medical referral pursuant to § 75-50-210 is found by his or her primary care physician to require an emergency medical referral, the Medical Referral Committee may authorize Medical Referral Services to assist with the arrangements for medical care to be provided outside the CNMI. However, such patient (or responsible party) shall be required to pay a flat fee of $250.00forlogisticalorotherrelatedcostsincurredbyMedicalReferralServices,plus$25.00 per hour if emergency medical evacuation is required. Modified, 1 CMC § 3806(a), (c), (d), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission substituted “Section 2.2 of these Rules and Regulations” with “§ 75-50- 210” pursuant to 1 CMC § 3806(c) and (d). Part 700 - Referral Fees § 75-50-701 Payment of Medical Referral Costs (a) Medical Referral Services is the payer of last resort. Prior to departing the CNMI, every patient approved for medical referral or their representative shall provide the Medical Referral Services staff with proof of any and all health care financial support and/or third-party payers, such as a health insurance identification card, Medicaid identification card, or Medicare claim card, that are responsible for providing financial coverage for the costs associated with the patient’s medical referral. Medical referral patients, or their representative, shall also execute a subrogation of claims form prior to their departure from the CNMI, authorizing Medical Referral Services, through the Office of the Attorney General, to pursue any legal claims on behalf of the patient against third parties who may be liable for payment of medical referral costs. (b) Medical Referral Services shall presume that the following entities or individuals are responsible for the following costs associated with the patient’s medical referral: (1) Recipients of Benefits from Medicaid, Medicare Vocational Rehabilitation or Other Government Assistance Programs: 100% of the program costs for medical, ancillary, transportation, escort, and maintenance costs incurred in connection with a patient’s medical referral shall be paid by the appropriate federal and/or CNMI government program(s). Any amount not covered by the government program(s) or another third party payer shall be the patient’s financial responsibility, except as provided in subsection (b)(6). (2) Health Care Insurance: 100% of policy limit coverage for medical, ancillary, transportation, escort, and maintenance costs incurred in connection with a patient’s medical referral pursuant to the terms and conditions of the patient’s health care insurance policy shall be © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 26 of 35

TITLE 75: OFFICE OF THE GOVERNOR paid by the insurance company (including HMOs and PPOs). If a patient’s health care insurance policy does not cover air transportation costs to a referral health care facility and maintenance costs, Medical Referral Services shall pay these costs as provided in §§ 75-50-315 and 75-50- 320. However, in cases where an insurance company prefers to make independent arrangements for its members’ medical referral, Medical Referral Services shall only be responsible for air transportation and maintenance costs up to the equivalent level of such costs for a medical referral to the State of Hawaii. Any amount not covered by the patient’s health care insurance policy or another third-party payer shall be the patient’s financial responsibility, except as provided in subsection (b)(6). (3) Nonresident Worker Health Medical Coverage: The patient, employer on record, or other responsible party shall be 100% responsible for all expenses incurred in connection with the patient’s medical referral. Medical Referral Services will assist only with coordination and logistical support at a flat fee of $250.00plus$25.00 per hour if emergency medical evacuation is required. (4) Third Party Acts Against a Patient: Medical Referral Services, with the assistance of the medical referral patient, shall use its best efforts to collect the costs incurred in connection with the patient’s medical referral from any or all of the following: (i) any third-party found guilty of a physical crime against the patient which resulted in the patient’s need for medical referral; (ii) any third-party tortfeasor whose actions injured the patient and resulted in the patient’s need for medical referral; and/or (iii) such third-parties’ insurance companies. (5) No Responsible Third-Party Payer: In the absence of a responsible third-party payer, 100% of the medical, ancillary and escort costs incurred in connection with the patient’s medical referral shall be the patient’s financial responsibility, or, if the patient is a minor, then the financial responsibility of a chargeable adult, except as provided in subsection (b)(6). Medical Referral Services will pay air transportation costs to a referral health care facility and maintenance costs, as provided in §§ 75-50-315 and 75-50-320. (6) Exceptions for Indigent Patients. Medical Referral Services shall pay the applicable percentage of the medical referral costs for which an indigent patient is personally liable whenever the patient is able to establish to the satisfaction of the Medical Referral Services staff that he or she falls within the indigent standards set forth below: (i) Medical Referral Services shall pay 100% of the medical and ancillary costs, transportation, official escort and maintenance costs associated with the medical referral of those patients whose family household gross income from all sources falls within the following levels: Family Size† Maximum Annual Income1 1 $18,0212$24,378 3 $30,7364$37,093 5 $43,4516$49,808 7 $56,1658$62,523 © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 27 of 35

TITLE 75: OFFICE OF THE GOVERNOR † For family units of more than 8 members, add 4,780 for each additional member. 1Maximum annual income levels are based on 133% and 150% respectively of the 2015 Poverty Level Guidelines for the State of Hawaii as measured by the Consumer Price Index, and are the levels published in the Federal Register on January 26, 2012 (volume 77, number 17) by the Secretary of the United States Department of Health & Human Services, Centers for Medicaid and Medicare Services, pursuant to the Omnibus Budget Reconciliation Act (OBRA) of 1981, §§ 652, 673(2). (ii) Medical Referral Services shall pay 75% of patients’ medical and ancillary costs, and 100% of transportation costs, including those of an official escort, as well as maintenance costs associated with the medical referral, for patients whose family gross income from all sources falls within the following levels: Family Size† Maximum Annual Income1 1 20,325 2 $27,4953$34,665 4 $41,8355$49,005 6 $56,1757$63,345 8 $70,515†Forfamilyunitsofmorethan8members,add$5,592 for each additional member. 1Maximum annual income levels are based on 133% and 150% respectively of the 2015 Poverty Level Guidelines for the State of Hawaii as measured by the Consumer Price Index, and are the levels published in the Federal Register on January 26, 2012 (volume 77, number 17) by the Secretary of the United States Department of Health & Human Services, Centers for Medicaid and Medicare Services, pursuant to the Omnibus Budget Reconciliation Act (OBRA) of 1981, §§ 652, 673(2). (c) Any amount not covered by the Medical Referral Program shall be the financial responsibility of the patient or the responsible party for a minor patient. (d) The patient or patient’s representative shall have the burden of providing the Medical Referral Services staff with verifiable documentation regarding the patient and the patient’s family unit (such as filed family income tax returns, wage and salary forms for employed family members, and applications for family enrollment in public assistance programs) that establish that the patient and the patient’s family unit fall within the indigent levels set forth above, and that the patient is thus eligible for financial assistance through Medical Referral Services. The Medical Referral Services staff shall include the documentation provided by the patient to establish indigent eligibility in the patient’s medical referral file. Medical Referral Services shall be prepared to demonstrate to the governor, upon request, that the patient satisfactorily established that he or she was indigent and required financial support to pay the medical referral cost. In doing so, no information beyond the patient and patient’s family unit’s financial information shall be shared outside Medical Referral Services. While the governor may review the case, the decision on the patient’s indigent status may not be changed by the governor or at © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 28 of 35

TITLE 75: OFFICE OF THE GOVERNOR the governor’s direction upon such review. Modified, 1 CMC § 3806(a), (b), (c), (d), (f), (g). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The original paragraphs were not designated. The Commission designated subsections (a) and (b). The Commission also designated subsections (b)(6)(iii) and (iv). The Commission converted the comma after the word “costs” in the first paragraph to a period pursuant to 1 CMC § 3806(g). The Commission corrected the spelling of the words “patient’s,” “HMOs” and “PPOs” in subsection (b) pursuant to 1 CMC § 3806(g). The Commission inserted a comma after the word “ancillary” in subsection (e) pursuant to 1 CMC § 3806(g). The Commission corrected the spelling of the word “patient’s” in subsection (f)(4) pursuant to 1 CMC § 3806(g). The Commission corrected the capitalization of the words “state” in subsections (a) and (b) and the words at the beginning of subsection (d)(1) through (d)(3) pursuant to 1 CMC § 3806(f). The Commission inserted commas after the words “Oregon” in subsection (a) and “record” in subsection (c) pursuant to 1 CMC § 3806(g). In March 2016, the Commission renumbered this section, numbered its unnumbered paragraphs, and renumbered its subsections pursuant to 1 CMC § 3806(a). The Commission rearranged the unnumbered paragraph and footnotes to fit harmoniously within this Code pursuant to 1 CMC § 3806(b). The Commission changed the reference numbers “Section 11.1.f” in subsections (b)(1), (b)(2), and (b)(5) to “subsection (b)(6)” and “Sections 5.3 and 5.5 of these Rules and Regulations” in subsections (b)(2) and (b)(5) to “§§ 75-50-315 and 75-50-320” to agree with the renumbered sections and subsections pursuant to 1 CMC § 3806(c) and (d). The Commission changed “ * ” in subsections (b)(6)(i)–(ii) to “ † ” pursuant to 1 CMC 3806(g). § 75-50-705 Assignment of Rights Every patient approved for medical referral must assign any and all rights he or she may have to health care financial support or other third-party payments to Medical Referral Services up to the entire costs of the medical referral, and shall use his or her best efforts to secure such financial assistance for the entire medical referral cost. If, at any time, a medical referral patient receives a direct reimbursement from an insurance company or other third-party payer for medical bills arising from an authorized medical referral, such patient shall immediately endorse such payment to Medical Referral Services for deposit in the Medical Referral Services account. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). § 75-50-710 Utilization Review (a) All medical bills incurred by a patient at the referral health care facility shall be subject to utilization review by the appropriate Medical Referral Services staff or contracted personnel. In © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 29 of 35

TITLE 75: OFFICE OF THE GOVERNOR those cases where a patient is referred to a referral health care facility in the State of Hawaii, it shall be the primary responsibility of the utilization review personnel employed by Medical Referral Services to review the medical treatment and care provided to the patient, and to audit the medical bills prior to their payment by Medical Referral Services. If, during a utilization review, it is determined that: (1) a patient is receiving, or has received, health care services that are unnecessary or unauthorized by the Medical Referral Committee; (2) the patient’s stay in the hospital has been unnecessarily extended; (3) irregularities or inconsistencies exist in the patient’s medical bills; and/or (4) there are other factors regarding patient care which may compromise the financial integrity or managed health care policy of Medical Referral Services, such personnel performing the utilization review shall immediately notify the Director of Medical Referral Services in writing of the situation. (b) The Medical Referral Services Director shall promptly notify the referral health care facility in writing about the conclusions reached in the utilization review report regarding the specific charges for unauthorized or inappropriate services and advise the facility that Medical Referral Services will not be responsible for such charges. In the event of an emergency that requires additional medical services after a patient has been referred, emergency referral procedures must be followed, although approval may be sought retrospectively (also using emergency referral procedures) if the patient is in clear danger of death if immediate action is not taken. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission corrected the capitalization of the word “state” in subsection (a) pursuant to 1 CMC § 3806(f). In March 2016, the Commission numbered the leading paragraph as subsection (a); renumbered subsections (a)–(d) to subsections (a)(1)–(4); and numbered the final paragraph as subsection (b) pursuant to 1 CMC § 3806(a). § 75-50-715 Lifetime Limit Medical Referral Services shall pay medical expenses incurred for medical referral up to a lifetime limit of eighty thousand dollars per eligible patient. Transportation and maintenance costs for the referral patient and their escort(s) shall not be included in the calculation of a patient’s lifetime limit. Any medical expense in excess of the lifetime limit shall be the patient’s full responsibility. Medical Referral Services shall only assist with applicable air transportation and maintenance costs for future referrals of patients who have reached or exceeded the lifetime limit. Any medical estimate or expense shall solely be the patient’s responsibility. MRS must verify patients’ abilities to pay estimated medical expenses prior to the issuance of a Medical Treatment Authorization Form and travel authorization. © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 30 of 35

TITLE 75: OFFICE OF THE GOVERNOR Modified, 1 CMC § 3806(a), (e). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission struck the figure “$50,000”andcorrectedthecapitalizationofthephrase“fiftythousanddollars”pursuantto1CMC\S 3806(e)and(f).InMarch2016,theCommissionstruckthefigure“($80,000)” as a mere repetition of written words pursuant to 1 CMC § 3806(e). Part 800 - Limited Government Liability § 75-50-801 Statutory Exemption As provided in 7 CMC § 2204(d), the CNMI Government shall not be liable for any claim arising from the Medical Referral Committee’s denial of, or failure to make, a medical referral to a medical facility outside the CNMI. Modified, 1 CMC § 3806(a), (d). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The Commission corrected the spelling of the word “Committee’s” pursuant to 1 CMC § 3806(g). The Commission substituted “Section 2204(d) of Title 7 of the Commonwealth Code” with “7 CMC § 2204(d)” pursuant to 1 CMC § 3806(d). § 75-50-805 Medical Referral Services Not Responsible for Unauthorized Services Medical Referral Services shall not be responsible for the medical, ancillary, transportation, escort, or maintenance costs incurred by a patient whose off-island medical care was not authorized by the Medical Referral Committee. Similarly, Medical Referral Services shall not be responsible for the cost of medical or health care services rendered to a patient at a health care facility or by a health care provider not recognized by the Medical Referral Committee. Modified, 1 CMC § 3806(a). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 31 of 35

TITLE 75: OFFICE OF THE GOVERNOR Part 900 - Miscellaneous Provisions § 75-50-901 Penalties for Violations of These Rules and Regulations Any person found by Medical Referral Services to have violated these rules and regulations shall be liable for either: (a) a civil penalty of up to $1,000;or(b)thecostsincurredbyMedicalReferralServicesasaresultoftheviolation,whicheverisgreater;andcourtcostsandattorneys’feesincurredbytheCNMIgovernmentincollectingsuchpenaltyorincurredcosts,foreachviolation.Suchdeterminationshallbemadebythedirector.Intheeventthepersonwhoisthesubjectofsuchafindingwishestoappeal,heorsheshallbeentitledtoanadministrativehearingconductedbyMedicalReferralServices.Furthermore,wheresuchviolationsappeartoconstituteacrime,themattermaybereferredtotheAttorneyGeneral’sOfficeand/ortheUnitedStatesAttorney’sOfficeforpossibleprosecution.Modified,1CMC\S 3806(a),(f).History:AmdtsAdopted38Com.Reg.37902(Mar.29,2016);AmdtsProposed38Com.Reg.37567(Feb.28,2016);AmdtsAdopted35Com.Reg.34128(Aug.28,2013)(repealingandre-enactingthissubchapter);AmdtsProposed35Com.Reg.33549(June28,2013);AmdtsAdopted33Com.Reg.31503(Apr.21,2011)(repealingandre-enactingthissubchapter);AmdtsProposed33Com.Reg.31291(Jan.24,2011);Emergency33Com.Reg.31225(Jan.24,2011);Adopted18Com.Reg.14218(July15,1996);Proposed18Com.Reg.14039(Apr.15,1996).CommissionComment:TheCommissionchanged“$1,000.00” in subsection (a) to “$1,000” pursuant to 1 CMC § 3806(g). § 75-50-905 Severability If any provision of this chapter or the application of any such provision to any person or circumstance should be held invalid by a court of competent jurisdiction, the remainder of this chapter, or the application of their provisions to persons or circumstances other than those to which they are held invalid, shall not be affected thereby. Modified, 1 CMC § 3806(a), (d). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: In March 2016, the Commission substituted “these Rules and Regulations” with “this chapter” pursuant to 1 CMC § 3806(d). © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 32 of 35

TITLE 75: OFFICE OF THE GOVERNOR Appendix A Referral Health Care Facilities For purposes of this chapter, the following health care facilities, and those health care providers and ancillary care providers associated with these facilities, shall be considered to be recognized referral health care facilities for medical referral patients from the CNMI: TERRITORY OF GUAM Cancer Center of Guam Dr. Byungsoo Kim Dr. Raymond M. Taniguchi Dr. Young Chang Dr. David Parks Dr. Pierre Pang Dr. Ruben Arafiles ENT and Neurology Clinic FHP Health Center Good Samaritan Clinic Guam Memorial Hospital Guam Pacific Medical Clinic Guam Seventh Day Adventist Clinic Guam Eye Clinic Guam Orthopedic Associates Guam Public Medical Clinic Guam Radiology Consultants Guam Pacific Medical Group Guam Regional Medical City Guam Surgicenter Guam Surgical Group Hafa Adai Specialist Group Health Partners IHP Island Eye Center Island Surgical Center Island Cancer Center Latte Stone Cancer Center Naval Hospital Guam Pacific Cardiology Consultants Pacific Medical Group Pacific Hand Surgery Pacific Surgical Arts Pacific Urology Consultants St. Lucy’s Eye Clinic U.S. Renal Care © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 33 of 35

TITLE 75: OFFICE OF THE GOVERNOR STATE OF CALIFORNIA Anaheim Memorial Hospital California Pacific Medical Center Children’s Hospital of LA. Good Samaritan Hospital, LA Rady Children’s Hospital (San Diego) UCSD UCSF UCLA STATE OF HAWAII Cancer Institute of Maui Cancer Center of Hawaii Castle Medical Center DSI Renal Clinic Kahi Mohala Center (Mental Health) KapioIani Children/Women Hospital (PIMS) Kaukini Medical Center Liberty Dialysis Center Pali Momi Medical Center (PIMS) Pacific Cardiology Queens Medical Center Renal Treatment Center Rehabilitation Hospital of the Pacific Shriners Hospitals for Children — Honolulu Straub Clinic and Hospital (PIMS) St. Francis Hospital Tripler Army Medical Center Waikiki Health Center REPUBLIC OF THE PHILIPPINES Asian Hospital and Medical Center Makati Medical Center The Medical City Hospital Philippine General Hospital St. Luke’s Medical Center (both) STATE OF TEXAS The Brown Schools of Central Texas (San Marcos Treatment Center, Health Care Rehabilitation Center, etc.) MD Anderson Cancer Center JAPAN Aichi Children’s Hospital © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 34 of 35

TITLE 75: OFFICE OF THE GOVERNOR Fukushima Memorial Hospital Nagoya City University Hospital Modified, 1 CMC § 3806(a), (f). History: Amdts Adopted 38 Com. Reg. 37902 (Mar. 29, 2016); Amdts Proposed 38 Com. Reg. 37567 (Feb. 28, 2016); Amdts Adopted 35 Com. Reg. 34128 (Aug. 28, 2013) (repealing and re-enacting this subchapter); Amdts Proposed 35 Com. Reg. 33549 (June 28, 2013); Amdts Adopted 33 Com. Reg. 31503 (Apr. 21, 2011) (repealing and re-enacting this subchapter); Amdts Proposed 33 Com. Reg. 31291 (Jan. 24, 2011); Emergency 33 Com. Reg. 31225 (Jan. 24, 2011); Amdts Emergency and Proposed 27 Com. Reg. 25187 (Nov. 25, 2005) (effective for 120 days from November 23, 2005); Amdts Adopted 27 Com. Reg. 24681 (July 20, 2005); Amdts Emergency and Proposed 27 Com. Reg. 24099 (Mar. 17, 2005) (effective for 120 days from March 14, 2005); Amdts Adopted 26 Com. Reg. 21894 (Feb. 23, 2004); Amdts Emergency and Proposed 26 Com. Reg. 21531 (Jan. 22, 2004) (effective for 120 days from Jan. 14, 2004); Amdts Adopted 20 Com. Reg. 15958 (June 15, 1998); Amdts Emergency and Proposed 20 Com. Reg. 15851 (Feb. 15, 1998) (effective for 120 days from Feb. 13, 1998); Adopted 18 Com. Reg. 14218 (July 15, 1996); Proposed 18 Com. Reg. 14039 (Apr. 15, 1996). Commission Comment: The November 2005 Emergency and Proposed amendments proposed to add two new facilities located in the state of California. As of December 2005, a notice of permanent adoption had not been published. In March 2016, the Commission numbered the Attachment I as Appendix A pursuant to 1 CMC § 3806(a). The Commission created the title to Appendix A. The Commission substituted “these Rules and Regulations” with “this chapter” pursuant to 1 CMC § 3806(d). © 2016 by The Commonwealth Law Revision Commission (August 30, 2016) Page 35 of 35

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Source: CNMI Law Revision Commission