P.R. Laws tit. 26, § 9003
For purposes of this Code, except in those chapters where a more specific definition is provided, the following terms shall have the meaning stated below:
(a) Covered benefits or Benefits.— Means the healthcare services to which a covered person or enrollee is entitled under a health plan.
(b) Insurance Code of Puerto Rico.— Refers to §§ 101 et seq. of this title.
(c) Commissioner.— Means the Commissioner of Insurance of Puerto Rico.
(d) Emergency medical condition.— Means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that would lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably expect that the absence of immediate medical attention could place an individual's health in serious jeopardy; result in serious dysfunction of a bodily organ or part; or for a pregnant woman who is having contractions, the lack of sufficient time to transfer her to other facilities before delivery, or that her transfer would result in serious jeopardy to her health or the health of her unborn child.
(e) Clinical review criteria.— Means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health insurance organization or issuer to determine medical necessity and appropriateness of healthcare services.
(f) Medical care.— Means:
(1) The diagnosis, mitigation, treatment, or prevention of disease.
(2) Transportation primarily for and essential to medical care referred to in clause (1).
(g) Dependent.— Means any person who is or may be eligible for a health plan due to his/her relationship with the subscriber and in accordance with the conditions set forth in the health plan. The following may be considered dependents of the subscriber:
(1) The spouse.
(2) A birth or adopted child or child placed for adoption under age twenty-six (26).
(3) A birth or adopted child or child placed for adoption who, regardless of his/her age, is incapable of earning a living due to mental or physical disability existing before he/she has attained twenty-six (26) years of age, as provided in Public Law 111-148, known as the Patient Protection and Affordable Care Act, Public Law 111-152, known as the Health Care and Education Reconciliation Act, and the regulations thereunder.
Stepchildren.
(4) Foster children who have lived since infancy under the same roof with the enrollee in a normal parent/child relationship and who are, and shall continue to be, totally dependent on the family of said enrollee to receive support, as provided in § 1633 of this title.
(5) Unemancipated minor whose custody has been awarded to the subscriber.
(6) A person of any age who has been declared incompetent by a court and whose custody has been awarded to the enrollee.
(7) A parent or parent-in-law of the main subscriber who permanently resides in the household of such main subscriber and is substantially dependent on him/her for support, and who may be classified in the optional or collateral dependents category, as such term is commonly accepted and defined in the health insurance market.
(8) A parent or parent-in-law of the main subscriber who does not reside in the household of such main subscriber, and who may be classified in the optional or collateral dependents category, as such term is commonly accepted and defined in the health insurance market.
(h) Healthcare facility or Facility.— Means a licensed institution providing healthcare services or a healthcare setting, including hospitals and other inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, radiology, and imaging centers; and rehabilitation and other therapeutic health settings.
(i) NAIC.— Refers to the National Association of Insurance Commissioners.
(j) Healthcare service organization.— Means any entity that contracts to provide or arrange for healthcare services to its subscribers, based on the prepayment thereof, except for the amount to be paid by the subscriber as copayment, coinsurance, or deductible, as provided in the chapter on Healthcare Service Organizations of this Code.
(k) Health insurance organization or Issuer.— Means an entity, subject to the insurance laws and regulations of Puerto Rico or subject to the jurisdiction of the Commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse the costs of healthcare services, including any for-profit or nonprofit hospital and medical service corporation, healthcare service organization, or any other entity providing health benefit, service, or care plans. Provided, That the entities excluded pursuant to Section 1.070 of the Insurance Code of Puerto Rico shall not be considered a health insurance organization or insurer for purposes of this Code.
(l) Covered person or Enrollee.— Means the holder of a policy or certificate, subscriber, or other individual participating in a health benefit plan.
(m) Person.— Means any natural or juridical person, including corporations, partnerships, associations, joint association, limited partnership, trust, unincorporated organization, and similar entities or combination thereof.
(n) Open-ended plan.— Means a managed care plan that offers incentives, including economic incentives, for covered persons or enrollees to use participating providers under the terms of a health plan.
(o) Closed plan.— Means a managed care plan that requires covered persons or enrollees to use only participating providers under the terms of a health plan.
(p) Managed care plan.— Means a health plan that provides economic or other kinds of incentives for covered persons or enrollees to use the participating providers of a healthcare service organization or issuer, or those that are administered, contracted, or employed by it.
(q) Indemnity health plan.— Means a health plan other than a managed care plan.
(r) Health plan.— Means a policy, contract, certificate, or agreement offered by a health insurance organization, healthcare service organization, or any other issuer provided in consideration of or in exchange for the payment of a premium, or on a prepaid basis, through which a health insurance organization, healthcare service organization, or any other issuer commits to provide coverage or pay for the costs of specified healthcare, hospital, major medical, dental, mental health, or incidental services to the rendering thereof.
(s) Healthcare professional.— Means a physician or other healthcare practitioner, licensed, accredited, or certified by the appropriate entities, to perform specified healthcare services consistent with the corresponding laws or regulations of the Commonwealth.
(t) Healthcare provider or Provider.— Means a healthcare professional or healthcare facility duly authorized to render or provide healthcare services.
(u) Participating provider.— Means a provider who, under a contract with a health insurance organization or issuer, or with its contractor or subcontractor, has agreed to provide healthcare services to covered persons or enrollees with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health insurance organization or insurer.
(v) Authorized representative.— Means:
(1) A person to whom the covered person or enrollee has given express written consent to represent him/her for purposes of this Code.
(2) A person authorized by law to provide substituted consent for a covered person or enrollee.
(3) A family member of the covered person or enrollee or the healthcare professional who is treating such covered person or enrollee when he/she is unable to provide consent.
(4) A healthcare professional if the covered person or enrollee's health plan requires that a request for benefits be initiated by the healthcare professional.
(5) For any urgent care request, a healthcare professional with knowledge of the covered person or enrollee's medical condition.
(w) Health Insurance Code Regulations.— Refer to the rules or regulations adopted by the Commissioner pursuant to any provision of this Code.
(x) Healthcare services or medical services.— Mean services for the diagnosis, prevention, treatment, cure, or relief of a chronic health condition, illness, injury, or disease.
(y) Emergency services.— Mean healthcare services furnished or required to treat an emergency medical condition.
(z) Subscriber.— Means an individual covered by a health plan issued by a healthcare service organization.
(aa) Urgent care.— Is a sudden illness that does not threaten the life or the integrity of a person, and may be treated in a physician's office or extended hours clinic, and not necessarily in an emergency room, but if it is not properly treated at the appropriate time, may become an emergency.
Notice This section has more than one version with varying effective dates. First of two versions of this section.
History —Aug. 29, 2011, No. 194, § 2.030, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 1, eff. 30 days after July 10, 2013; July 15, 2014, No. 90, § 1.