P.R. Laws tit. 26, § 9005
Any provision of this Code that is in conflict or deals with matters regulated by any federal law, regulations, or administrative rule issued by a federal agency and applicable to Puerto Rico in the fields of healthcare or health plans shall be deemed to be amended to conform to such federal law or regulations. In addition:
(a) No issuer or health insurance organization offering group or individual health plans shall establish:
(1) Lifetime limits on covered essential health benefits, in accordance with 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 adopted thereunder.
(2) Unreasonable annual limits on covered essential health benefits, pursuant to 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 adopted thereunder.
(b) Subsection (a) of this section shall not be construed to prevent an issuer or health insurance organization offering group or individual health plans that are not required to provide essential health benefits, as such term is defined in federal and Commonwealth laws and regulations, from placing annual or lifetime limits on specific covered benefits to the extent that such limits are otherwise permitted under federal or Commonwealth law.
(c) An issuer or health insurance organization offering group or individual health plans shall, at least, provide coverage and shall not impose any cost-sharing requirements for the following preventive care services, insofar as the covered persons receives the same from a participating provider:
(1) Services included in the latest recommendations of the United States Preventive Services Task Force.
(2) Immunizations that have a recommendation in effect from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices of the Department of Health of Puerto Rico.
(3) With respect to infants, children, and adolescents up to twenty-one (21) years of age, preventive care and screening services provided in the comprehensive guidelines supported by the Health Resources and Services Administration.
(4) With respect to women, preventive care and screening services as provided in the comprehensive guidelines supported by the Health Resources and Services Administration, including services related to breast cancer screening.
(d) Every issuer or health insurance organization offering group or individual health plans shall ensure that all levels of coverage include the Essential Health Benefits Package required by Section 1302(a) of the Patient Protection and Affordable Care Act and this subsection. The Essential Health Benefits Package constitutes a health plan that includes:
(1) The following benefits:
(A) Ambulatory and medical surgical services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services.
(F) Laboratory, x-ray, and diagnostic testing services.
(G) Pediatric services, including the respiratory syncytial virus vaccine and the cervical cancer vaccine, as well as oral and vision care.
(H) Prescription drugs.
(I) Rehabilitative and habilitative services.
(J) Preventive and wellness services and chronic disease management.
(K) Any other mandatory service or benefit required by Commonwealth or federal laws or regulations.
(2) Limitation on the imposition of cost-sharing requirements for such coverage, as provided in Section 1302(c) of the Patient Protection and Affordable Care Act and the previous subsection (c); and
(3) Any of the metal plans, in the bronze, silver, gold, or platinum level of coverage, as described in Section 1302(d) of the Patient Protection and Affordable Care Act, and below:
(A) Bronze Level.—A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to sixty percent (60%) of the full actuarial value of the benefits provided under the plan.
(B) Silver Level.—A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to seventy percent (70%) of the full actuarial value of the benefits provided under the plan.
(C) Gold Level.—A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to eighty percent (80%) of the full actuarial value of the benefits provided under the plan.
(D) Platinum Level.—A plan in the platinum level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to ninety percent (90%) of the full actuarial value of the benefits provided under the plan.
If an issuer or health insurance organization offers a metal plan in any of the levels of coverage described in Section 1302(d) of the Patient Protection and Affordable Care Act and in this subsection, said issuer shall offer such metal plan in the same level of coverage to any enrollee who, at the beginning of the policy year, has not attained twenty-one (21) years of age.
(e) Nothing provided in this section shall be construed to prohibit an issuer or health insurance organization from providing benefits in excess of those described herein.
(f) No group or individual health plan that includes emergency service coverage shall require prior authorization for such services, whether the healthcare provider is a participating provider or not.
(g) Every group or individual health plan that requires the designation of a primary care provider when the enrollee is eighteen (18) years or less shall permit the designation of a physician who specializes in pediatrics as the child’s primary care provider, provided that such provider participates in the network of participating providers of the health plan. In addition, the health insurance organization or issuer may require the primary care provider to initiate a referral for specialty care and maintain supervision of healthcare services rendered to the covered person or enrollee.
(h) A health insurance organization or issuer shall not require prior authorization or referral to obtain obstetrical and gynecological care provided by participating providers who specialize in obstetrics and gynecology.
A group or individual health plan that provides coverage for obstetric or gynecologic care and, at the same time, requires the designation of a primary care provider shall treat the provision of obstetrical and gynecological care, and the ordering of related obstetrical and gynecological services, as the primary care provider.
(i) No individual or group health plan shall not impose any preexisting condition exclusion in the case of persons under nineteen (19) years of age. After 2014, the right to nondiscrimination based on preexisting conditions shall apply to all persons regardless of their age.
(j) A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to individuals or group of persons once the enrollee is covered under such plan, except in cases that involve fraud or an intentional misrepresentation of material fact by the enrollee or the person applying for health insurance on behalf of another person as prohibited by the terms of the plan or coverage. The health insurance organization or issuer that wishes to rescind or cancel health plan coverage shall issue a notice, with at least thirty (30) days in advance, to every health plan subscriber, or primary subscriber in the case of individual health plans, who may be affected by the proposed rescission or cancellation of coverage.
(k) Health insurance organizations or issuers of individual or PYMES employer-sponsored health insurance coverage shall make direct use of at least eighty percent (80%) of the premiums to provide healthcare and to improve the quality of healthcare received by the enrollee. In the case of large groups, such ratio shall be eighty-five percent (85%). Large groups are those with more than fifty (50) employees or members and which, by 2016, shall have more than one hundred (100) employees of members.
In the event that a health insurance organization or issuer fails to comply with this provision, the difference shall be reimbursed to the subscriber.
(l) Health insurance organizations or issuers shall not discriminate in favor of highly compensated individuals, as such term is defined in the U.S. Internal Revenue Code and the pertinent regulations, in group plans in terms of eligibility or benefits offered to highly compensated individuals.
(m) The rights established in this section shall have the scope and be governed by the requirements and procedures set forth 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 adopted thereunder.
History —Aug. 29, 2011, No. 194, § 2.050, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 2, eff. 30 days after July 10, 2013.