P.R. Laws tit. 24, § 7032
Healthcare plans shall have a broad coverage, with a minimum of exclusions. There shall be no exclusions for pre-existing conditions, or waiting periods at the time coverage is granted to a beneficiary.
(a) Coverage A.— The Administration shall establish a coverage of benefits to be offered by the contracted insurers or participating providers. The coverage shall include, among others, the following benefits: outpatient services, hospitalizations, dental health, mental health, Human Papillomavirus vaccines and treatment, studies, testing, and equipment for beneficiaries who require the use of a ventilator for life support, laboratory tests, and X-rays, as well as prescription medications, which shall be dispensed by a participating pharmacy, freely chosen by the insured and licensed under the laws of Puerto Rico. The coverage shall provide for each beneficiary to have available the laboratory tests and immunizations appropriate for his age, sex, and physical condition annually. Provided, however, That the list of medications for HIV/AIDS patients shall be reviewed annually in order to include those new medications, should the Administration deem it pertinent, that are needed for the treatment of said condition which shall be dispensed and offered in accordance with the best medical practices, provided that it does not affect the State Plan executed by the Department of Health and the Health Resources and Services Administration.
The Administration shall revise this coverage periodically.
(b) Coverage B.— Hospital services coverage shall be available twenty-four (24) hours a day, every day of the year.
(c) Coverage C.— In its out-patient coverage, the plans shall include the following, without it being a limitation:
(1) Preventive health services:
(a) Vaccination of children and adults up to eighteen (18) years of age.
(b) Vaccination against influenza and pneumonia for persons over sixty-five (65) years of age, and/or children and adults with high risk illnesses such as pulmonary, kidney, diabetes and heart diseases, among others.
(c) Visit to the primary physician for a general medical examination once a year. In the case of the students who are beneficiaries of this plan, they shall be entitled to the annual screening tests required by §§ 183 et seq. of this title, and to a certification issued by their primary physician to such effects.
(d) Screening test to detect gynecologic, breast and prostate cancer, according to acceptable practices.
(e) Sigmoidoscopy in adults over fifty (50) years of age having a risk of cancer of the colon, according to acceptable practices.
(2) Evaluation and treatment of beneficiaries with known diseases:
The initial evaluation and treatment of beneficiaries shall be made by the primary physician chosen by the patient among the providers of the corresponding plan.
(3) Access to health services provided by licensed nutrition and dietetics professionals.— With a referral from a primary physician, all beneficiaries may freely select a licensed nutritionist or dietetics professional. Beneficiaries shall freely select their licensed nutrition and dietetics professional from providers in the network contracted by the insurer of the area.
(4) Access to Human Papillomavirus vaccination treatment, which shall consist of three (3) doses to be administered according to the indications of the health professional. This coverage shall not be limited exclusively to the treatment mentioned in this subsection, but rather shall be extended to any other treatment or vaccine that could be developed for the treatment and prevention of Human Papillomavirus.
(5) The Administration shall file a report with the Legislative Assembly every six (6) months, which shall include, among others, the list of medications, any disputes that have arisen with respect to the State Plan executed by the Department of Health and the Health Resources and Services Administration, and the number of patients affected by these disputes.
Primary physicians shall have the responsibility of the out-patient management of the beneficiaries under their care, providing them with continuity of services. Likewise, they shall be the only ones authorized to refer the beneficiary to the supporting physicians and primary purveyors.
History —Sept. 7, 1993, No. 72, Art. VI, § 8, renumbered as § 6 on Dec. 29, 2000, No. 463, § 7; July 19, 2002, No. 105, § 4; Sept. 23, 2004, No. 482, § 1; Nov. 3, 2006, No. 236, § 1; Sept. 21, 2007, No. 125, § 1; June 2, 2008, No. 78, § 1; June 27, 2008, No. 100, § 1; Aug. 8, 2010, No. 123, § 6; Aug. 22, 2012, No. 192, § 1.