P.R. Laws tit. 24, § 7029
All residents of Puerto Rico may be beneficiaries of the Health Plan established upon the implementation of this chapter, provided that they meet the following requirements, as pertinent:
(a) Be identified and certified by the Department, as provided by § 7025 of this title. Provided, That all persons eligible to receive federal health benefits, shall obtain their services as provided through the applicable federal legislation, or regulations also having the right to Commonwealth health services that may be available and adequate for their condition, that are not covered under the federal health benefits.
(b) Members of the Puerto Rico Police, as well as their spouses and children, pursuant to the provisions of §§ 3101 et seq. of Title 25.
When a member of the Puerto Rico Police dies under any circumstance, this benefit shall remain in force for the surviving spouse, as long as the spouse does not remarry, and the children are younger than twenty-one (21) years of age, or for those who are undertaking post-secondary studies, until they are twenty-five (25) years of age. The Puerto Rico Police shall consign the funds in its budget of expenses to continue providing the health insurance plan to these beneficiaries by means of a contribution equal to the health benefit contribution received by the member of the Police force from his/her employer at the moment of his/her death.
In the event that the member of the Puerto Rico Police dies, the agency shall notify the surviving spouse and/or underage children about their right to continue enjoying the coverage of the Government Health Insurance Plan, and they must accept or decline such continued coverage in writing.
(1) Such beneficiaries shall have a term of ninety (90) days to notify whether they accept or decline the benefit and, within said ninety (90)-day term, no changes in health benefits may be made unless the notice is answered before the term expires.
(2) The Puerto Rico Police shall notify any changes in the health benefits of dependents of a police officer fallen in the line of duty to the Department of Health. It is provided that the Medical Assistance Program (Medicaid) shall notify the dependent(s) of the deceased police officer of the rights they are entitled to under this chapter.
(c) Those public employees and their direct dependents who, due to their financial condition, qualify as beneficiaries of the Health Insurance Plan of the Government of Puerto Rico, shall be entitled to receive this benefit. The corresponding difference to cover the total cost of the individual and family medical and hospital coverage insurance premium shall arise from the funds appropriated by the Office of Management and Budget.
Public employees whose income level does not allow them to be eligible for the Plan may opt to avail themselves, together with their dependents, of the Health Plan of the Government of Puerto Rico or to continue benefiting from a private plan of their preference. If they choose to join the Government’s Health Plan, the difference between the government’s contribution and the cost of the premium shall be defrayed by the employees.
In the case of married individuals both of whom are public employees, they may avail themselves of the Health Plan and combine their contributions and act jointly for their eligibility. In all instances, the Secretary of the Treasury, the municipality, or the public corporation shall transfer to the Administration the sum corresponding to the employer contribution of such public employees benefiting from the Health Plan. Public employees who choose to use the employer contribution to acquire another health plan available in the market and who, in turn, have been identified and certified by the Department, as provided in § 7025 of this title, shall not participate in the Health Plan of the Government of Puerto Rico. Public employees shall have the choice of extending their medical hospital coverage to their optional dependents, and the employee shall defray the cost of such coverage in its entirety.
For purposes of this subsection, the term “public employees” includes the employees of the public corporations and the municipalities. The Administration shall prescribe a premium payment system by regulations.
(d) The pensioners of the Central Government of the Commonwealth of Puerto Rico, according to the Implementation Plan of the Administration. The Secretary of the Treasury shall transfer to the Administration the corresponding sum of the employer contribution for pensioners of the Central Government agencies. The pensioners shall have the option of extending the medical-hospital coverage to their direct and optional dependents, and the pensioner shall defray the full cost of the coverage. The pensioners who opt to use the employer contribution to acquire another medical insurance plan in the market shall not participate in the plan established herein.
(e) Employees of small- and medium-sized businesses, (better known as PYMES), who are interested in subscribing to the plan established herein and, should they be entitled, allow their employer to transfer to the Administration or to the insurer the corresponding sum of the employer contribution, in addition to the payment of the contribution of the employee, until the cost of the insurance premium for hospital medical benefits is covered, both for individual and family coverage; except in the case where the employer contribution covers the full cost of the insurance coverage. For purposes of this subsection, small- and medium- sized businesses are those having between one (1) and fifty (50) employees. In these cases, the Administration shall adopt regulations as necessary for the implementation and operation of this Health Plan, so as to establish what its coverage shall include and what benefits shall be provided, the eligibility criteria, and the premium payment system.
(f) Veterans, their spouses and children, certified by the Federal Medical Assistance Program, pursuant to the provisions of Act No. 13 of October 2, 1980.
(g) Veterans, their spouses and children under twenty-one (21) years of age who are dependent on their parents for their care and support, if interested in doing so, may pay the Administration or the Insurer the corresponding sum for the cost of the insurance premium to cover medical-hospital benefits, for both the individual as well as family coverage.
(h) Individuals, personally, and regardless of their position at work; employees whose employers do not provide them with a health plan; and self-employed individuals and their dependents. In these cases, the Administration shall adopt regulations as necessary for the implementation and operation of this Health Plan so as to establish what its coverage shall include and what benefits shall be provided, the eligibility criteria and the premium payment system.
(i) Members of associations, cooperatives, professional associations, or colleges of persons authorized to practice their professions by the Government of Puerto Rico; trade associations or colleges; federal, state, or municipal associations; and the American Association of Retired Persons (AARP), interested in benefiting from such plan and that transfer to the Administration or to the Insurer the corresponding sum of the cost of the insurance premium for hospital medical benefits, both for individual and family coverage. In these cases, the Administration shall adopt regulations as necessary for the implementation and operation of this Health Plan so as to establish what its coverage shall include and what benefits shall be provided, the eligibility criteria, and the premium payment system.
History —Sept. 7, 1993, No. 72, Art. VI, § 5; June 13, 1998, No. 83, § 1; June 22, 2000, No. 107, § 2; renumbered as § 3 on Dec. 29, 2000, No. 463, § 5; Aug. 10, 2001, No. 100, § 1; July 19, 2002, No. 105, § 4; Oct. 19, 2009, No. 127, § 1; Dec. 15, 2010, No. 197, § 1; Dec. 15, 2010, No. 198, § 1.