P.R. Laws tit. 26, § 9132
(a) The Commissioner shall authorize the manner and level in which the PYMES employer issuer shall provide coverage according to this chapter and the provisions of § 9005 of this title.
(b) The Commissioner shall provide the benefit levels, cost-sharing, exclusions, and limitations of the basic health plan in its different metal levels or variations, taking into account all the provisions imposed by state and federal laws and regulations. Health plans authorized by the Commissioner shall include cost control measures such as the following:
(1) Utilization review of healthcare services, including review of medical necessity of hospital and physician services;
(2) improve quality and access to services, preventive programs and case management, among others;
(3) selective contracting with hospitals, physicians and other healthcare providers;
(4) reasonable benefit differentials applicable to providers that participate or do not participate in arrangements using preferred network provisions, and
(5) other managed care provisions.
(c) The Commissioner may establish, through policy letter, the requirements of a basic health plan in its different metal levels, as well as other health plans he/she deems convenient to fulfill the purposes described in this section. After this initial recommendation, and at least once a year, the Commissioner shall promulgate the necessary amendments to such health plans.
History —Aug. 29, 2011, No. 194, § 8.120, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 21, eff. 30 days after July 10, 2013.