P.R. Laws tit. 24, § 7031
The Administration shall establish the premium agreed to in the contracts underwritten with the insurers and/or health service organizations. It shall also establish in said contracts the corresponding amount as payment of deductibles and co-insurance according to the level of income and ability to pay of the beneficiary. All other insurers and/or health service organizations may come to an agreement with the Administration to pay a premium that is higher than the basic premium, the difference of which shall be paid by the beneficiary. No participating provider may charge the beneficiary an amount that exceeds the amount agreed upon as a deductible, co-insurance, or premium in the contract underwritten with the insurers or the Administration.
The insurers and/or health service organizations that contract with the Administration to provide health plans shall not, at any time, increase the premium or reduce benefits in any other policies they provide, in order to subsidize the premium, reduce the cost, or compensate for the loss experienced by the health plan that is authorized in this chapter. The premium agreed upon must be actuarially validated as reasonable by the duly qualified actuaries of the Administration according to the standards of the American Academy of Actuaries. For the purpose of structuring and fixing the cost or premium, the insurers and/or health service organizations shall consider the group of beneficiaries of these health insurance plans as a unit that is independent from its other groups of beneficiaries, and shall maintain a separate accounting system for them. Likewise, the health service providers that contract with the Administration may not reduce the benefits or affect the quality thereof to accommodate patients that are not covered by the health plan authorized by this chapter.
Failure to comply with the provisions of this section shall be penalized by the Insurance Commissioner pursuant to the provisions of §§ 101 et seq. of Title 26, denominated the “Insurance Code of Puerto Rico”, or by the provisions of the contract with the Administration, as applicable.
History —Sept. 7, 1993, No. 72, Art. VI, § 7, renumbered as § 5 and amended on Dec. 29, 2000, No. 463, § 6; July 19, 2002, No. 105, § 4; Aug. 8, 2010, No. 123, § 5.