Guam became a U.S. territory in 1950 and created a Medicaid program in 1975. Its Medicaid program is administered by the Guam Department of Public Health and Social Services (CMS 2016a).

For Medicaid and the State Children’s Health Insurance Program (CHIP), Guam is considered a state unless otherwise indicated (§ 1101(a)(1) of the Social Security Act (the Act)). However, its Medicaid program differs in many aspects from those in the 50 states and District of Columbia.

Eligibility rules in Guam’s Medicaid program differ in some ways from those in the states. Guam is permitted to use a local poverty level to establish income-based eligibility for Medicaid. It is exempt statutorily from requirements to extend poverty-related eligibility to children and pregnant women (§ 1902(l)(4)(B) of the Act), and qualified Medicare beneficiaries (§ 1905(p)(4)(A) of the Act). Guam currently provides coverage to individuals, including children, with modified adjusted gross incomes up to 133% of the Guam poverty level (GPL). This is $1,536 per month for a family of four or approximately 61 % of the federal poverty level, which is $2,500 per month for four in 2021. Guam has expanded Medicaid eligibility to the new adult group under the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended). Guam uses CHIP funds as an additional funding source for children in Medicaid after it has exhausted its Medicaid allotment. It does not offer coverage to children whose incomes are above the threshold for Medicaid eligibility.

Federal rules for Medicaid benefits generally apply to Guam, and its Medicaid program provides all mandatory and many optional benefits, including dental coverage and prescription drugs. Guam is the only territory that covers all mandatory benefits, including nursing facility services. Enrollees can receive care outside of the territory with prior authorization, when medically necessary, and when services are not provided in Guam. All Medicaid enrollees under age 21 can receive early and periodic screening, diagnostic, and treatment (EPSDT) services.

Guam provides Medicare cost-sharing assistance to dually eligible individuals who qualify for full Medicaid benefits. It does not offer Medicare cost-sharing assistance to individuals who may be eligible as partial dually eligible individuals in the states—that is, through Medicare Savings Programs—because these programs are not available in Guam or the other territories. Guam’s Medicaid program covers Medicare Part B premiums for individuals dually eligible for Medicare and Medicaid. No Medicare Part D plans are currently available in Guam. Still, dually eligible individuals with cost-sharing for prescription drugs can receive subsidies through the Enhanced Allotment Plan, also referred to as 1935(e) funding.

Guam’s annual Section 1108 allotment was set in the statute when its Medicaid program was established in 1975 and grew with the medical component of the Consumer Price Index for All Urban Consumers (§ 1108(g) of the Act). Guam’s CHIP allotment is determined by the Centers for Medicare & Medicaid Services (CMS) based on prior-year spending; the same methodology used for states. In general, once Guam exhausts its annual federal Medicaid and CHIP allotments, it must fund its program with local funds. However, Congress has provided time-limited supplemental federal Medicaid funds to Guam and other territories on several occasions, most recently through the FY 2020 appropriations package, signed into law on December 20, 2019 (P.L. 116-94) and the Families First Coronavirus Response Act, signed into law on March 18, 2020 (FFCRA, P.L. 116-127). These actions raised Guam’s FY 2020 allotment from $18.4 million to $130.9 million, and it is FY 2021 allotment from approximately $18.8 million to $129.7 million.

The Federal Medical Assistance Percentage FMAP for Guam and the territories is statutorily set at 55 % (§ 1905(b) of the Act), unlike that of the states, where the FMAP is set using a formula based on state per capita income. For FYs 2020 and 2021, Guam has a temporary FMAP of 83%. During the national emergency declared in response to the COVID-19 outbreak, Guam will receive the 6.2 percentage point increase provided by FFCRA to all states and territories, effective January 1, 2020. This brings Guam’s FMAP to 89.2 % during the emergency period. Guam will also receive a 100 % CHIP enhanced FMAP during the emergency period. Like the states and other territories, Guam’s matching rate for almost all program administration is set at 50 % (§ 1903(a)(7) of the Act).