P.R. Laws tit. 26, § 9163
As used in this chapter, the term:
(a) Affiliate or affiliated to.— Means “affiliate” as defined in §§ 9121-9137 of this title.
(b) Geographic service area.— Means a geographic area as defined in §§ 9121-9137 of this title.
(c) Issuer or Individual health plan issuer.— Means a health insurance organization or issuer as defined in §§ 9001-9008 of this title, that issues or offers individual health plans for the purpose of providing coverage to one or more residents of Puerto Rico. The term insurer shall include health service organizations unless otherwise excluded from the text.
(d) Association or Health plan issuer association.— Means a nonprofit corporation established in accordance with § 9172 of this title.
(e) Bona fide association.— Means any entity that meets all of the following criteria:
(1) Only market association memberships, accept applications for membership, or sign up members who are actively engaged in, or directly related to, the profession represented by the association or the objective pursued by the same.
(2) Has been actively in existence for at least five (5) years.
(3) Has a constitution and by-laws or other analogous governing documents thereto.
(4) Has been formed and maintained in good faith for purposes other than obtaining health insurance.
(5) It is not owned or controlled by an issuer or affiliated with an issuer.
(6) Does not condition membership in the association on any health status-related factor.
(7) All members and dependents of members are eligible for the health plan regardless of any health status-related factor.
(8) Does not make a health plan offered through the association available other than in connection with a member of the association.
(9) Is governed by a board of directors and sponsors general annual meetings of members.
(10) A labor union shall not constitute a bona fide association for purposes of this subtitle.
(f) Restrictions relating to rates.— Means:
(1) Family composition.
(2) Geographic service area.
(3) Tobacco use.
(4) Age.
(5) Other factors as established by the Commissioner through a policy letter.
(g) Actuarial certification.— Means a written statement from a member of the American Academy of Actuaries or other person as determined by the Commissioner, which establishes that the individual health plan issuer has complied with the provisions of § 9165 of this title, the rest of this chapter, as well as with the applicable rules, laws, and policy letters, based upon the examination of the appropriate records and the actuarial assumptions and methods used by the issuer in establishing premiums for the applicable individual health plan.
(h) Family composition.— Means:
(1) Enrollee.
(2) Enrollee, spouse and children.
(3) Enrollee and partner.
(4) Enrollee and children; or
(5) Child only.
(6) Enrollee and domestic partner.
It shall be understood as children all of those identified as such in the definition of dependents set forth in §§ 9001-9008 of this title. For purposes of this definition, domestic partner means persons who are single, of legal age and with full legal capacity, live together voluntarily and share a domestic life in a stable and ongoing manner.
(i) Preexisting condition.— Means a condition, including genetic information, regardless of the cause of the condition, for which treatment, care, or diagnosis was received or recommended before the effective date of the health plan. Starting on January 1, 2014, current or future health plans shall not exclude or discriminate against any beneficiaries due to a preexisting condition, regardless of the enrollee’s age.
(j) Creditable coverage.— Means a “creditable coverage as defined in §§ 9121-9137 of this title. A period of creditable coverage shall not be counted, with respect to the enrollment of an individual who seeks coverage under this chapter, if, after such period and before the enrollment date, the individual experiences a significant break in coverage.
(k) Qualifying previous coverage or Qualifying existing coverage.— Means benefits or coverage that provides any of the following:
(1) Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (now TRICARE) or the Indian Health Service or any government sponsored program.
(2) Any group health plan including coverage issued by a health insurance organization or issuer, a prepaid hospital or medical care plan or a fraternal benefit society that provides benefits similar to or exceeding those provided under a basic health plan, provided that the coverage has been in effect for a period of at least one year.
(3) An employer-sponsored health plan under a self-funded health plan that provides benefits similar to or exceeding those provided under a basic health plan, provided that coverage has been current, at the least, for the past twelve (12) consecutive months, if
(A) The employer elected a health plan that participates in the health plan issuer association pursuant to § 9173 of this title, and
(B) the employer met the requirements for participation in the plan of operation of the health plan issuer association.
(4) An individual or a bona fide association health plan, including coverage provided by a health insurance organization or issuer, a prepaid hospital or medical care plan or a fraternal benefit society which provides benefits that are similar to those offered by a basic health insurance plan under a Silver level of coverage, or that exceeds them, if the policy has been current, at the least, for the past twelve (12) consecutive months.
(5) Commonwealth coverage provided under a health plan for uninsurable individuals if the policy has been current for at least one year.
(l) Preferred network provision.— Means the provision of an individual health plan that conditions the payment of benefits, in whole or in part, to the use of healthcare providers that have entered into a contractual arrangement with the issuer, in other words, a participating healthcare provider for covered persons.
(m) Qualifying event.— Means the loss of eligibility pursuant to the terms of the policy.
(n) Health status-related factor.— Means the factors listed in §§ 9121-9137 of this title.
(o) Enrollment date.— Means enrollment date as defined in §§ 9121-9137 of this title.
(p) Genetic information.— Means “genetic information” as defined in §§ 9121-9137 of this title.
(q) Significant break in coverage.— Means a period of sixty-three (63) consecutive days during all of which the individual does not have any creditable coverage. Neither a waiting period nor an affiliation period shall be taken into account in determining a significant break in coverage.
(r) MI Salud.— Means the Government Health Plan of the Health Insurance Administration established by virtue of §§ 7001 et seq. of Title 24, known as the “Puerto Rico Health Insurance Administration Act”.
(s) Attributable loss.— Means the amount computed pursuant to § 9172 of this title.
(t) Enrollment period.— Means a period of time during the year established for individuals to enroll in a health plan. This period must elapse before coverage under a health plan becomes effective and during which the issuer shall not be required to provide benefits.
(u) Waiting period.— Means “waiting period” as defined in §§ 9121-9137 of this title.
(v) Rating period.— Means the calendar period for which premium rates established by issuers, subject to this chapter, are in effect.
(w) Recently insured individual.— Means a person who is a resident of Puerto Rico and who had qualifying previous coverage within the past thirty (30) days, or an individual who has had a qualifying event occur within the past thirty (30) days.
(x) Eligible person.— Means a person who is a resident of Puerto Rico and not eligible to be insured under an employer-sponsored health plan. The term may include the following:
(1) Enrollee.
(2) Enrollee, spouse, and children.
(3) Enrollee and spouse.
(4) Enrollee and children; or
(5) Child only.
(6) Enrollee and domestic partner.
(y) Federally defined eligible individual.—
(1) An individual:
(A) For whom, as of the date on which the individual seeks coverage under this chapter, the aggregate of the periods of creditable coverage, as defined in subsection (j), is eighteen (18) or more months.
(B) Who has had a creditable coverage.
(C) Whose most recent creditable coverage and enrollment date are not more than sixty-three (63) days apart.
(D) Who is not eligible for coverage under a group health plan, Part A or Part B of Title XVIII of the Social Security Act, or a Commonwealth plan under Title XIX of such Act, or any successor program, and who does not have other health insurance coverage.
(E) With respect to whom the most recent coverage within the period of aggregate creditable coverage was not terminated based on a factor relating to nonpayment of premiums or fraud.
(z) Bona fide association plan.— Means a health plan offered through a bona fide association that covers members of a bona fide association and their dependents in Puerto Rico, and which meets the following criteria:
(1) The plan complies with the provisions of § 9165 of this title concerning rates as they apply to individual health plan issuers. If the coverage is not contingent upon employer contribution and is offered to individuals, it shall not be treated as group health plan or health plan for PYMES employer. If the health plan offered by the bona fide association covers at least two thousand (2,000) members, the association’s experience pool can be the basis for setting rates. If the bona fide association plan covers fewer than two thousand (2,000) members of the bona fide association, the issuer shall community rate the experience of that bona fide association with the experience of other bona fide associations covered by the issuer following the risk spreading method to develop rates.
(2) Provides renewability of coverage for the members of the association and their dependents, pursuant to the criteria of § 9166 of this title.
(3) Provides coverage under the bona fide association health plan to the members thereof and their dependents who are eligible pursuant to the provisions of subsections (a) and (b) of § 9167 of this title or § 9168 of this title, except that the bona fide association shall not be required to offer individual basic health plans in any of its metal levels of coverage.
(4) The plan is offered by an issuer who provides individual health plans, and
(5) The plan complies with the preexisting condition provisions as they apply to individual health plans.
(aa) Preferred network plan.— Means “preferred network plan” as defined in §§ 9121-9137 of this title.
(bb) Church plan.— Shall have the meaning given to such term in Section 3(33) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended.
(cc) Federal governmental plan.— Shall have the meaning given to such term in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, and any Federal governmental plan.
(dd) Health plan.— Means a “health plan” as defined in §§ 9121-9137 of this title.
(ee) Individual basic health plan.— Means a health plan that meets the requirements of the Essential Health Benefit Package developed in accordance with §§ 9005 of this title and as defined in the regulations adopted under the provisions of the “Patient Protection and Affordable Care Act”.
(ff) Group health plan.—
(1) Means an employee welfare plan as defined in Section 3(1) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, to the extent that the plan provides medical care and including items and services paid for as medical care to employees or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.
(2) For purposes of this chapter:
(A) Any plan, fund, or program that would not be, but for Section 2721(e) of the Public Health Service Act (PHSA), as added in the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Pub. L. 104-191), an employee welfare benefit plan and that is established or maintained by an association, to the extent that such plan provides medical care, including items and services paid for as medical care, to present or former partners in the partnership or to their dependents, as defined under the terms of the plan, fund, or program, directly or through insurance, indemnification, or otherwise, shall be treated as an employee welfare benefit plan;
(B) in the case of a group health plan, the term “employer” shall also include the partnership in relation to any partner, and
(C) The term “participant” shall include individuals who are eligible to receive a benefit under the plan or their beneficiaries or the individuals and their beneficiaries who may become eligible to receive any such benefit, if:
(i) In connection with a group health plan maintained by the partnership, the individual is a partner in relation to the partnership, or
(ii) in connection with a group health plan maintained by a self-employed individual, under which one or more employees are participants, he/she is the self-employed individual.
(gg) Individual health plan.— Means:
(1) A plan acquired by an individual for him/herself and/or his/her family, including student health insurance coverage. A health insurance plan other than a converted policy, an employer-sponsored health plan, or a bona fide association health plan or certificate for individuals and their dependents, and
(2) a certificate issued to an enrollee as evidence of coverage under a policy, or contract issued to a trust or association or a similar group of individuals, regardless of the circumstances or the place of delivery of the policy or contract, if the enrollee pays the premium and is not being covered under the policy or contract pursuant to the continuation of benefits of provisions applicable under Federal and Commonwealth laws.
(hh) Converted policy.— Means a basic health plan in its different metal levels of coverage issued pursuant to the provisions of this chapter and the applicable federal provisions.
(ii) Premium.— Means a specific amount of money paid to an issuer as a condition of receiving benefits under a health plan, including any fees or other contributions associated with the health plan.
(jj) Producer.— Means “producer” as defined in §§ 9121-9137 of this title.
(kk) Subscriber.— Means “subscriber” as defined in §§ 9001-9008 of this title.
(ll) Enrollee or Covered person.— Means, for purposes of this chapter, a person who:
(1) Is covered under an individual health plan, and
(2) has paid a premium for him/herself or his/her dependents, if any, who are also covered under the individual health plan, and is responsible for the continuous premium payment under the terms of the individual health plan.
(3) For purposes of this chapter, the term enrollee includes subscribers, unless specifically excluded from the text or otherwise specified.
History —Aug. 29, 2011, No. 194, added as § 10.030 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.