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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8051/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8051 - Declaration of purposes
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8051 - Declaration of purposes
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In view of the problem of financial loss as a result of uncompensated damages to motor vehicles in traffic accidents, the Government of Puerto Rico, through this chapter, adopts a compulsory liability insurance system which covers the damages caused to vehicles in accidents. To such ends, so that a motor vehicle can travel on public thoroughfares, its owner shall obtain and keep a liability insurance coverage in effect. This coverage responds for damages caused to motor vehicles of third parties as a result of a traffic accident, for which the owner of the vehicle covered by this insurance is legally liable and which, through its use, has caused said damages.
To enforce the compulsory nature of the insurance coverage, the cost thereof shall be paid on the date the vehicle’s license is acquired for the first time or upon renewal thereof. The compulsory coverage cannot be cancelled, except as provided in § 8053(c) of this title, nor is it refundable, and at the time of acquisition shall be paid in full, except as provided in § 8061(a) of this title.
History —Dec. 27, 1995, No. 253, § 2; Dec. 29, 2009, No. 201, § 1.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8052/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8052 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8052 - Definitions
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For the purposes of this chapter, the following terms and phrases shall have the meaning stated below:
(a) Insurer.— Means a private insurer as well as the Joint Underwriting Association.
(b) Private insurer. — Means an insurer who is or may be licensed in the future to underwrite insurance in Puerto Rico, against any loss, expense or liability for the loss or the damage caused to persons or property resulting from the possession, conservation or use of a land vehicle, airship, or draft animals or mounts, or incidental thereto, all of which [is] pursuant to § 407 of this title; provided, that the volume of premiums underwritten for that type of insurance by said insurer is greater than one percent (1%) of the total volume of premiums underwritten in Puerto Rico for the same.
(c) Joint Underwriting Association.— Means the Compulsory Liability Insurance Joint Underwriting Association, a private association in charge of providing and administering the compulsory liability insurance acquired through the payment of fees for the [issuance] or renewal of a motor vehicle license, created by this chapter.
(d) Code.— Means Act June 19, 1957, No. 77, as amended, denominated as the “Insurance Code of Puerto Rico”, §§ 101 et seq. of this title.
(e) Commissioner.— Means the Insurance Commissoner of Puerto Rico.
(f) Entities authorized to collect the compulsory liability insurance.— Means the entities authorized by the Secretary of the Treasury and the Secretary of Transportation and Public Works to collect the payment of fees for the issuance or renewal of a motor vehicle license together with the payment of the compulsory liability insurance.
(g) Uniform policy form.— Means the policy form of identical content to be used by all insurers to underwrite compulsory liability insurance.
(h) Puerto Rico Vehicle and Traffic Act.— Means §§ 5001 et seq. of Title 9.
(i) Motor vehicle license.— Means any motor vehicle certificate of registration issued pursuant to §§ 5001 et seq. of Title 9.
(j) Uniform premium.— Means the maximum uniform premium to be charged for the compulsory liability insurance for private passenger vehicles or for commercial vehicles.
(k) Compulsory liability insurance.— Means the insurance required by this chapter and that responds for damages caused to third party motor vehicles as a result of a traffic accident, for which the owner of the vehicle covered by this insurance is legally liable, and through its use, the damages occurred according to the system for the initial determination of liability created pursuant to this chapter. Said insurance shall have coverage of four thousand dollars ($4,000) per accident. The Joint Underwriting Association may review and modify the coverage and the compulsory liability insurance policy every two (2) years, in accordance with its financial stability and actuarial studies. However, the coverage may never be less than three thousand dollars ($3,000). The Joint Underwriting Association shall notify the determined coverage and policy to the Commissioner.
(l) Traditional liability insurance.— Means a vehicle insurance as defined in § 407 of this title, different from what is defined in subsection (j) of this section, and underwritten by private insurers.
(m) Commercial vehicles.— Means those motor vehicles that the Department of Transportation and Public Works does not register as private automobiles, automobiles owned by disabled persons, or motorcycles. The term “commercial vehicle” includes trailer trucks of more than two (2) tons registered as such in said Department.
(n) Motor vehicle.— Means and includes commercial vehicles and private passenger vehicles.
(o) Private passenger vehicles.— Means those motor vehicles that the Department of Transportation and Public Works registers as private automobiles, automobiles owned by disabled persons, and motorcycles.
History —Dec. 27, 1995, No. 253, § 3; Aug. 20, 1997, No. 94, § 1; Dec. 26, 1997, No. 201, § 1; Dec. 29, 2009, No. 201, § 2.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8053/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8053 - General provisions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8053 - General provisions
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(a) Any person who obtains a motor vehicle license for the first time, or who renews it, as required by §§ 5001 et seq. of Title 9, shall be bound to pay the corresponding premium for the compulsory liability insurance together with the payment of the amount of the fees for the issuing or renewing said license, to the Secretary of the Treasury. The Secretary of the Treasury shall transfer the total amount of the premiums collected to the Joint Underwriting Association.
However, the Joint Underwriting Association may establish through regulations to such effects, alternate methods for the payment of the premium for the compulsory liability insurance, provided there is assurance that the issuing or renewal of the motor vehicle license shall be subject to the owner of the said vehicle being insured either by traditional liability insurance or by the compulsory liability insurance.
The Secretary of Transportation and Public Works shall deny the [issuance] or renewal of any motor vehicle license in the name of any person who fails to comply with this provision.
(b) No person shall drive, conduct or operate a motor vehicle or allow the vehicle to travel on the public thoroughfares if he/she has not yet acquired compulsory liability insurance.
Every incidental owner or driver of a motor vehicle must ascertain that the vehicle being driven is covered by a compulsory liability insurance policy before traveling on the public thoroughfares of the country.
(c) The compulsory liability insurance shall be in effect during the term for which the motor vehicle license is issued and can only be cancelled when the subject of the insurance disappears, or in those circumstances in which it is guaranteed that the motor vehicle shall continue to be insured by insurance with a coverage similar to or greater than the compulsory liability insurance. To such effects, the Commissioner shall establish, through regulations, under what conditions the cancellation for the above reasons shall be carried out.
(d) Any motor vehicle owner who wishes to acquire compulsory liability insurance, may freely select the insurer he/she shall request the insurance from. The private insurers that offer this coverage may select their insured pursuant to the provisions of § 8054(b) of this title.
(e) When the motor vehicle license is transferred to another person, the compulsory liability insurance which covers said vehicle shall be kept in effect and shall then cover the legal liability of the new owner until the date of renewal of said motor vehicle’s license.
History —Dec. 27, 1995, No. 253, § 4; Aug. 20, 1997, No. 94, § 2; Dec. 26, 1997, No. 201, § 2; Aug. 7, 1998, No. 201, § 1; Dec. 29, 2009, No. 201, § 3.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8054/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8054 - Who shall offer the compulsory liability insurance
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8054 - Who shall offer the compulsory liability insurance
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(a) All private insurers shall be bound to provide the compulsory liability insurance to those motor vehicle owners that request it, except as provided in subsection (b) of this section.
(b) The Commissioner shall establish the criteria through regulations to such effects, that the private insurers shall take into consideration to reject the applicants for compulsory liability insurance. If those criteria are not met, the Commissioner shall impose the penalties prescribed by this title for violations to its provisions on the [sic] private insurers.
(c) The compulsory liability insurance shall be underwritten by private insurers through the use of a uniform policy form which shall be subject to the provisions of §§ 1101–1137 of this title.
(d) The private insurers that underwrite compulsory liability insurance shall provide an information and orientation program on said insurance to the public, with special emphasis on the procedure to file the corresponding claims in cases of traffic accidents and in accordance with the guidelines that the Commissioner shall promulgate. Likewise, said official shall establish an information and orientation program which supplements that of the private insurers.
History —Dec. 27, 1995, No. 253, § 5; Aug. 20, 1997, No. 94, § 3.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8055/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8055 - Joint Underwriting Association—Creation
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8055 - Joint Underwriting Association—Creation
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(a) The Joint Underwriting Association of the Compulsory Liability Insurance is hereby created as a private association that shall provide and administer the compulsory liability insurance, which shall be acquired through the payment of fees for the [issuance] or renewal of a motor vehicle license. It shall be composed of private insurers that meet the underwriting requirements of this chapter. Each one of the private insurers shall be a member of the Joint Underwriting Association as a condition to continue offering any type of insurance in Puerto Rico.
(b) The main purpose of the Joint Underwriting Association shall be to provide compulsory liability insurance for motor vehicles to persons who do not have traditional liability insurance and that have paid the corresponding coverage fees for the [issuance] and renewal of motor vehicle licenses, or to the applicants for said insurance who have been rejected by private insurers.
(c) The Joint Underwriting Association shall receive from the Secretary of the Treasury the sum proceeding from the compulsory liability insurance that is paid directly by the consumer or insured to the Department of the Treasury pursuant to the following weekly transfer schedule:
(1) On or before noon on Friday of the first week of each month, the Department of the Treasury shall electronically transfer to the financial institution designated by the Joint Underwriting Association the fixed sum of two million dollars ($2,000,000).
(2) On or before noon on Friday of the second week of each month, the Department of the Treasury shall electronically transfer to the financial institution designated by the Joint Underwriting Association the fixed sum of two million dollars ($2,000,000).
(3) On or before noon on Friday of the third week of each month, the Department of the Treasury shall electronically transfer to the financial institution designated by the Joint Underwriting Association the remainder of the premiums collected during the previous month that were not transferred to the Joint Underwriting Association during that past month. The transfer to be made during that third week shall consist of the collections made by the Department of the Treasury on the previous month for compulsory liability insurance premiums minus the total sum of the premiums transferred to the Joint Underwriting Association during that past month.
However, no amount shall be remitted to the Association on that third week when, on making the aforementioned reconciliation, there is a balance in favor of the Department of the Treasury because the amount of the premiums transferred to the Association in the previous month is greater than the premiums actually collected for that month. The amount of said balance in favor of the Department of the Treasury shall be deducted from subsequent transfers, as deemed necessary to settle the balance in favor of the agency.
(4) On or before noon on Friday of the fourth week of each month, the Department of the Treasury shall electronically transfer to the financial institution designated by the Joint Underwriting Association the fixed sum of two million dollars ($2,000,000).
Every six (6) months, the Department of the Treasury and the Joint Underwriting Association shall review the fixed sums paid under the aforesaid schedule to determine if the transfer of the compulsory liability insurance premiums are being adequately transferred and to verify that the monthly amount that is transferred in a fixed manner is not less than seventy-five percent (75%) of the average of the monthly premiums actually collected by the Department of the Treasury during said period. This review shall guarantee that the fixed amounts to be subsequently transferred reflect at least seventy-five percent (75%) of the monthly premiums actually collected by the Department of the Treasury during the preceding period.
If the Secretary of the Treasury fails to comply with the transfer schedule established in this subsection, he/she shall have the obligation to pay to the Association, without the need of previous requirement to such respect, an additional amount equal to the interest generated by the amount not transferred as of the time in which said transfer should have been made, at the interest rate established in the last bond issue of the Government of Puerto Rico. However, under no circumstances shall the Secretary of the Treasury be authorized to retain collected compulsory liability insurance premiums for a term exceeding forty-five (45) days.
The premiums paid through entities authorized to collect compulsory liability insurance, together with the payment of the fees of motor vehicle licenses, shall be duly debited by the Joint Underwriting Association or transferred to it, as established by the Association. The Joint Underwriting Association shall establish, through regulations or corporate policy, the procedure that shall rule the collection and transfer of said premiums. The Joint Underwriting Association may require authorized entities to collect compulsory liability insurance to remit to it the information required in subsection (l) of this section.
The amount of the compulsory liability insurance premiums shall be eventually distributed between private insurers and the Joint Underwriting Association, as it may be appropriate. The administrative and operating expenses of the Joint Underwriting Association shall be charged to the amount of premiums corresponding to it in accordance with this distribution. The operating plan of the Joint Underwriting Association shall establish the form and manner in which the distribution of the amount of premiums received by the Joint Underwriting Association shall be made.
The Joint Underwriting Association shall conduct, at least once a year, a validation or corroboration process of the premiums received from the compulsory liability insurance collected by the Department of the Treasury and other entities authorized to collect the same. The Department of the Treasury, the Department of Transportation and Public Works, and other authorized entities shall be required to furnish the documents and information necessary for the Joint Underwriting Association to conduct said process. If there is a discrepancy between the amounts collected by the Department of the Treasury or by any other authorized entity and the amounts submitted to the Joint Underwriting Association, it shall be submitted to the consideration of an independent arbitrator selected by the concerned parties. The determination of the arbitrator shall be final and cannot be appealed, and all expenses incurred in the proceedings before the arbitrator shall be the responsibility of the losing party.
The Secretary of the Treasury shall deduct from the funds or premiums transferred to the Joint Underwriting Association a service fee for the collection of the premiums collected directly by the Department of the Treasury, which shall be based on a percent of the total of the premiums collected and remitted. The percent to be retained for said fee shall depend on the net income, after the payment of taxes by the Joint Underwriting Association for the previous tax year. This collections service fee does not constitute a tax on the premiums.
If the net income of the Joint Underwriting Association after the payment of taxes for the previous tax year is:
The service fee shall be
Negative (loss) 1%
Not more than $5,000,000 2%
In excess of $5,000,000, but less than $12,000,000 3%
In excess of $12,000,000, but less than $20,000,000 4%
In excess of $20,000,000 5%
(d) The Joint Underwriting Association shall have the general corporate powers of a private corporation and those provided in § 2905 of this title, and the power to negotiate those contracts and to determine the human resources that are appropriate to carry out its purposes. The Joint Underwriting Association shall be considered a stock insurer as such term is defined in § 2903 of this title.
(e) All members of the Joint Underwriting Association shall share in the profits and losses thereof, in the percentage that the direct net premiums underwritten in Puerto Rico during the previous year for each one of the insurers, for insurance against any loss, expense or liability for the loss or the damage caused to persons or property, resulting from the possession, conservation or use of a land vehicle, airship, or draft animal or mount, or incidental thereto, all of which is pursuant to § 407(1) of this title, represented by of the total of the direct net premiums underwritten in Puerto Rico during said year for that type of insurance.
(f) The Joint Underwriting Association shall establish its structure and operations through an operational plan, and its direction through a Board of Directors. This plan shall provide for an economical, fair, and nondiscriminatory administration of the affairs of the Joint Underwriting Association. The operational plan may be amended by the members that constitute the Joint Underwriting Association and its Board of Directors. The operational plan and its amendments shall be notified to the Commissioner.
The Board of Directors of the Joint Underwriting Association shall consist of seven (7) members, three (3) of which shall be appointed by the Governor of the Commonwealth of Puerto Rico, and the remaining four (4) shall be members of the Joint Underwriting Association elected in an annual meeting.
The appointments made by the Governor shall be formally notified by the latter to the Joint Underwriting Association. The members appointed by the Governor shall not be public officials and must have knowledge about the insurance industry. A member appointed by the Governor who, in the course of his/her functions, has a conflict of interest or a potential conflict of interest, as determined by the Joint Underwriting Association, shall be immediately removed from office. To such effect, the Joint Underwriting Association shall notify such fact to the Governor not later than ten (10) days after the removal from office has occurred. The Governor shall proceed to appoint a substitute for the remainder of the term corresponding to the outgoing member. In case of a vacancy in the office of a director elected by the members of the Joint Underwriting Association, the latter shall substitute him/her with one selected by the members of the Association.
The four (4) directors elected by the members of the Joint Underwriting Association shall hold office for a term of three years. The three (3) members appointed by the Governor shall hold office for a term of two (2) years.
The Board of Directors shall appoint the President of the Joint Underwriting Association and shall fix his/her salary.
(g) Neither the Board of Directors of the Joint Underwriting Association, [nor] its directors, personally or individually, shall be held financially liable for any action taken in the performance of their duties and powers under this chapter, which in the case of private insurers shall include both the insurer member as well as his/her representative on the Board of Directors, nor the officials of the Joint Underwriting Association, provided they are not acting intentionally to cause harm or knowing that they may cause harm.
(h) Any member of the Board of Directors who, individually or jointly, among themselves or with other insurer members of the Joint Underwriting Association, and acting in violation of their fiduciary duties, with the Joint Underwriting Association, incur any action which, directly or indirectly, impairs the financial interests of the Joint Underwriting Association, using or disclosing internal information of the Joint Underwriting Association which is not equally accessible to an insurer member, or fail to disclose internal information with the purpose of benefiting or damaging one or several private insurers, shall be liable, individually or jointly, as the case may be to the Joint Underwriting Association or the damaged private insurer, with a sum equal to three (3) times the financial cost which said actions have represented to them.
(i) Any benefit obtained from the operation of the Joint Underwriting Association, as well as any benefit that reverts to its members, shall be subject to the payment of income tax pursuant to the provisions of the Puerto Rico Internal Revenue Code.
(j) The Joint Underwriting Association shall transfer to the Secretary of the Treasury the funds designated in its annual statement as “Funds Retained by the Insurer Belonging to Others”. The Joint Underwriting Association shall transfer those amounts that represent the items that on the close on December 31 have remained in its books for more than two (2) years counting from the date on which the premiums were collected through the [issuance] or renewal of a motor vehicle license. Said transfers shall be made annually by March 30 of the year following the close to which the transfer corresponds. In case that the item “Funds Retained by the Insurer Belonging to Others” was overestimated, the Joint Underwriting Association shall submit evidence that proves the same to the Department of the Treasury. The Department of the Treasury shall proceed to reimburse or credit the total of those overestimated amounts to the Joint Underwriting Association. In case that the amounts were underestimated, the Joint Underwriting Association shall notify the Department of the Treasury and shall remit the corresponding amounts to the latter. In such cases, both parties shall have ninety (90) days as of the notification and presentation of the attesting evidence to make the reimbursement or credit of the corresponding amounts. For the purposes of this section, credit shall be understood to be the monetary amount that the Joint Underwriting Association or the Department of the Treasury can prospectively deduct from the payment of the service fees for the collection of premiums or from the next transfer from the aforementioned Retained Funds item.
The Secretary of the Treasury shall retain the funds transferred by the Joint Underwriting Association in its fiduciary capacity for a five (5)-year term counting from the date in which the retained funds are transferred by the Joint Underwriting Association to the Secretary of the Treasury.
The income generated by these funds shall revert to the General Fund of the Commonwealth Treasury as they are accrued. The Secretary of the Treasury shall establish a procedure for processing the reimbursement request of any person alleging a right to the retained funds. Once five (5) years have elapsed without the consumer claiming the retained funds, these shall become property of the Commonwealth of Puerto Rico and they shall be transferred to the General Fund of the Commonwealth Treasury.
(k) The Joint Underwriting Association may deposit in the Government Development Bank of Puerto Rico or in the Economic Development Bank of Puerto Rico all or part of the funds that it presently invests and that it receives from the Department of the Treasury as premiums paid by the consumer, provided that it complies with the provisions of the Insurance Code of Puerto Rico. The income accrued by the Association from funds deposited in the Government Development Bank or in the Economic Development Bank, which shall offer competitive rates according to the applicable laws, rules and regulations, shall be exempt from the payment of income tax.
(l)
(1) The Secretary of the Treasury shall provide the Joint Underwriting Association a monthly digital list of all license stickers acquired, for purposes of identification, by consumers or insured persons who, upon acquiring their license sticker, purchase the compulsory motor vehicle liability insurance at the Internal Revenue Collections Offices, financial institutions, and official inspection stations, should the latter apply. Said list shall contain the name and address of the insured person, the vehicle identification number (VIN number), the license sticker number, the date of payment, the date of expiration, and the license plate number. The list shall also contain the number of the certificate of compliance that has been used to exempt payment of the compulsory liability insurance in the case of those motor vehicles that have traditional liability insurance. The Department of Transportation and Public Works shall be responsible for providing to the Department of the Treasury and to the Joint Underwriting Association a monthly digital list with the name and address of the insured and the motor vehicle identification number (VIN number), so that the Department of the Treasury may provide all the required information to the Joint Underwriting Association and vice versa.
(2) In the case of all those license stickers acquired by consumers or insured persons through entities authorized to collect the compulsory liability insurance together with the payment of motor vehicle license fees, the Joint Underwriting Association may require them to provide a digital list that shall contain name and address of the insured, and the vehicle identification number (VIN number), the license sticker number, the date of payment, the date of expiration, and the license plate number. The list shall also contain the number of the certificate of compliance that has been used to exempt payment of the compulsory liability insurance in the case of those motor vehicles that have traditional liability insurance.
The Department of Transportation and Public Works shall provide the Department of the Treasury with the information needed to comply with the transmittal of the necessary data. The Department of Transportation and Public Works and the Department of the Treasury shall be responsible for providing the Joint Underwriting Association with the aforementioned information corresponding to the insured person and for overseeing compliance with these requirements by entities authorized to collect the compulsory liability insurance.
—Dec. 27, 1995, No. 253, § 6; Aug. 20, 1997, No. 94, § 4; Dec. 26, 1997, No. 201, § 3; Sept. 11, 2002, No. 230, §§ 1–3; Sept. 22, 2004, No. 414, § 1; Aug. 26, 2005, No. 106, § 1; Sept. 14, 2006, No. 200, § 1; Mar. 16, 2007, No. 26, § 1; Dec. 29, 2009, No. 201, § 4.
History
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8056/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8056 - Premiums
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8056 - Premiums
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(a) The initial uniform premium of the compulsory liability insurance shall be ninety-nine dollars ($99) for each private passenger vehicle and one hundred forty-eight dollars ($148) for each commercial vehicle. The premium shall not be increased until three (3) years have elapsed in the case of private insurers, and two (2) years in the case of the Joint Underwriting Association, both terms counted as of the date in which the compulsory liability insurance is exigible.
The Commissioner may fix a premium other than that established herein for the compulsory liability insurance of those vehicles to which the Department of Transportation and Public Works has issued transitory or provisional licenses.
(b) The uniform premium of the compulsory liability insurance applicable to private passenger vehicles and commercial vehicles, as well as that of motor vehicles insured with the Joint Underwriting Association, may be revised pursuant to the applicable provisions of §§ 1201–1240 of this title.
(c) Any private insurer may submit for the approval of the Commissioner a variation of a uniform percentage to reduce the uniform compulsory liability insurance premium corresponding to private passenger vehicles or commercial vehicles, pursuant to the provisions of § 1214 of this title.
(d) The Joint Underwriting Association, taking as [a] basis the frequency and severity of the losses of its insured, may submit for approval by the Commissioner those rules and rate plans that contain norms for the application of surcharges to the corresponding uniform premium of private passenger or commercial vehicles insured thereby, subject to the provisions of §§ 1201–1240 of this title. Such rules and rate plans shall provide for the prompt elimination or modification of said surcharges, upon the approval of the Commissioner, when the premium and loss experience thus justifies it.
(e) Any modification, alteration, change, reduction, or increase in the uniform compulsory liability insurance premium shall be made pursuant to the applicable provisions of Chapter 12 of the Code.
(f) The uniform premium of the compulsory liability insurance shall not be subject to the payment of premium taxes established in § 702 of this title.
History —Dec. 27, 1995, No. 253, § 7; Aug. 20, 1997, No. 94, § 5; Dec. 29, 2009, No. 201, § 5.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8057/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8057 - Investigation, adjustment and resolution of claims
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8057 - Investigation, adjustment and resolution of claims
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(a) The Joint Underwriting Association shall establish an initial liability determination system that shall facilitate, expedite, and uniform the payment of claims. Said system shall provide a reasonable term to make the liability determination. This system shall not impair the right of claimants to resort to the courts when the initial liability determination system thus allows or when any of the parties involved in a claim intend to obtain a compensation in addition to that paid by virtue of said system.
(b) The initial liability determination system originally drafted shall be reviewed or amended by the Joint Underwriting Association or its Board of Directors. The review or amendments shall be submitted to the consideration of the Commissioner. The amended determination system shall take effect immediately after its adoption by the Commissioner.
(c) The Commissioner may amend the initial liability determination system through the establishment of a taskforce composed of two (2) representatives from the Office of the Insurance Commissioner selected by the Commissioner, two (2) representatives from the Joint Underwriting Association selected by its Board of Directors, and one (1) member independently selected by mutual agreement of the Commissioner and the Joint Underwriting Association.
History —Dec. 27, 1995, No. 253, § 8; Dec. 26, 1997, No. 201, § 4; Dec. 29, 2009, No. 201, § 6.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8058/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8058 - Term for the payment of claims and penalties
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8058 - Term for the payment of claims and penalties
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Once the liability and the amount of the damages to a motor vehicle in an accident has been determined through the initial liability determination system or by the courts with jurisdiction, payment of the claim shall be made in a term which shall not exceed five (5) calendar days as of said determination. If payment is made after said term, the insurer shall be subject to an additional charge calculated on the basis of the prevailing legal interest for [sic] the benefit of the claimant. Furthermore, in these cases, the Commissioner may impose any administrative fines provided in the Code. The insurer shall make the corresponding payment to the owner of the affected motor vehicle or to the body shop selected by the affected person or both. The Joint Underwriting Association shall only accept repair estimates and shall only make payments to body shops that are duly registered in the Registry of Merchants of the Department of the Treasury. For such purpose, the Department of the Treasury shall periodically provide to the Joint Underwriting Association an updated list of body shops registered in the Registry of Merchants of said Department. For purposes of this section, the owner of the vehicle is that who appears as owner in the Department of Transportation and Public Works at the time the accident occurred, or the lessee in a lease contract subscribed under the provisions of the “Act to Regulate Personal Property Lease Contracts”, §§ 2401 et seq. of Title 10.
History —Dec. 27, 1995, No. 253, § 9; Sept. 2, 2000, No. 305, § 1; Dec. 29, 2009, No. 201, § 7.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8059/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8059 - Prescription
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8059 - Prescription
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Any right to a claim against an insurer under the compulsory liability insurance shall prescribe after one (1) year has elapsed since the cause of action occurred.
History —Dec. 27, 1995, No. 253, § 10.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8060/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8060 - Penalty for driving an uninsured motor vehicle
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8060 - Penalty for driving an uninsured motor vehicle
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(a) Any person who fails to comply with the provisions of § 8053(b) of this title shall incur a misdemeanor and, upon conviction, shall be sanctioned with a five hundred dollar ($500) fine. Furthermore, the court shall impose the payment of damages, as established in Section 16-102A [sic] of the Puerto Rico Vehicles and Traffic Act, for damages caused to an insured motor vehicle when it determines that said person caused it, and nothing provided herein shall affect any civil actions that may be filed.
When a law enforcement officer intervenes with any person, the former shall verify the effectiveness of the vehicle registration sticker, and if the person has failed to comply with the provisions of § 8053(b) of this title, the officer shall seize the license plate of the uninsured motor vehicle and issue the corresponding traffic ticket for violation of the provisions of this chapter and shall indicate said fact in the corresponding Police Report. The officer shall also remit said license plate to the Department of Transportation and Public Works within a term of no more than three (3) working days after the seizure. In those cases, said motor vehicle shall not be able to travel on public thoroughfares in Puerto Rico and the cost of its removal shall be assumed by the driver or owner of said vehicle. The owner may request the return of the seized license plate to the Secretary of the Department of Transportation and Public Works once he/she provides evidence of having complied with the provisions of this chapter.
(b) Any person who has failed to comply with the provisions in § 8053 of this title, whose motor vehicle is not insured, and who is involved in a traffic accident with a motor vehicle insured pursuant to the chapter, shall not be entitled to the benefits of the compulsory liability insurance for the damages to his/her motor vehicle. Likewise, the owner of a motor vehicle insured pursuant to this chapter, who causes damage to an uninsured motor vehicle, shall be exempted from liability for the damages covered by the insurance provided by this chapter, up to the limit thereof. Likewise, an authorized driver of an insured motor vehicle who causes damage to an uninsured motor vehicle, shall enjoy the same exemption as [does] the owner of such vehicle.
History —Dec. 27, 1995, No. 253, § 11; Aug. 20, 1997, No. 94, § 6; Aug. 7, 1998, No. 201, § 2; Dec. 29, 2009, No. 201, § 8.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8061/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8061 - Relationship between traditional liability insurance and compulsory liability insurance
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8061 - Relationship between traditional liability insurance and compulsory liability insurance
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(a) Those motor vehicle owners who have traditional liability insurance in effect at the time of the [issuance] or renewal of the motor vehicle license with a coverage similar to or greater than that of the compulsory liability insurance may continue to use said traditional insurance to comply with the insurance requirements established in this chapter.
Private insurers, agents, or brokers shall issue a certification authorized by the Joint Underwriting Association to persons or clients insured by them as evidence of compliance with the compulsory liability insurance in those cases in which the owner of a motor vehicle has traditional liability insurance or a coverage similar to or greater than that of the compulsory liability insurance. This certification of compliance shall have the effect of exempting said vehicle from the payment of the item corresponding to the compulsory liability insurance when paying the motor vehicle license fee.
(b) The Commissioner is hereby empowered to establish, through regulations, those measures that may be necessary so that motor vehicle owners who comply with the insurance requirements of subsection (a) of this section may present attesting proof of the [sic] said compliance, so that a fair and efficient coordination between the compulsory liability insurance and traditional liability insurance can be attained. The Commissioner shall also ensure that the private insurer who underwrites the traditional liability insurance acknowledges in the premiums charged for said insurance the amount of the payment received in compliance of the requirements stipulated in § 8053(a) of this title.
—Dec. 27, 1995, No. 253, § 12; Aug. 20, 1997, No. 94, § 7; Dec. 29, 2009, No. 201, § 9.
History
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-50/8062/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062)›§ 8062 - Annual report
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 50 - Compulsory Motor Vehicle Liability Insurance (§§ 8051 — 8062) › § 8062 - Annual report
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The Joint Underwriting Association shall submit an annual report to the Legislative Assembly at the Office of the Secretary and Clerk of each legislative body on or before March 15 of every year, which shall detail the incidence of accidents covered and the costs incurred in the repair of damages to motor vehicles insured by the Joint Underwriting Association.
History —Dec. 27, 1995, No. 253, added as § 13 on Dec. 29, 2009, No. 201, § 10.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-51/8071/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074)›§ 8071 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074) › § 8071 - Definitions
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For the purpose of this chapter:
(a) Medical emergencies.— Shall mean any medical condition manifested by acute or severe symptoms that could include severe pain, before which a lay person with average medicine and health knowledge may think that the lack of medical assistance could result in:
(1) A health risk for a person; Provided, That, in the cases of pregnant women, it means a woman’s health risk due to her pregnancy;
(2) deterioration of the body functions, and
(3) dysfunction of an organ or part of the body.
(b) 9-1-1 system.— Shall mean the fast response system to public safety emergency calls by dialing 9-1-1, created pursuant to §§ 1911 et seq. of Title 25, known as the “Act for Speedy Attention of Public Safety 9-1-1 Calls” or “9-1-1 Calls Act”.
History —Sept. 6, 2000, No. 383, § 1.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-51/8072/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074)›§ 8072 - Applicability
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074) › § 8072 - Applicability
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This chapter shall apply to the following entities:
(a) Insurance companies and health plans, nonprofit organizations that render health services to individuals or groups, under medical insurance policies issued or underwritten in Puerto Rico, or
(b) to health maintenance organizations (HMO), as defined in subsection (x) of § 334 of Title 24, that provide hospital, medical or surgical benefits to individuals or groups under contracts signed or executed in Puerto Rico.
History —Sept. 6, 2000, No. 383, § 2.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-51/8073/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074)›§ 8073 - Prohibitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074) › § 8073 - Prohibitions
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For the purpose of this chapter:
(a) Any entity subject to its provisions shall not favor nor instruct its clients or insured people to exclusively contact a medical emergency system other than 9-1-1 during an emergency. It is provided that any entity subject to the provisions of this chapter may use a transportation system other than 9-1-1, but cannot prohibit its insured or clients to contact the 9-1-1 system for non-emergency medical cases.
(b) No entity subject to the provisions of this chapter shall require its insured or clients to obtain a preauthorization to contact the 9-1-1 system in case of a medical emergency.
(c) No entity subject to the provisions of this chapter may use false or deceitful language in the written material distributed to its insured or clients; or language prohibiting them or making them desist from contacting the 9-1-1 system in case of a medical emergency.
History —Sept. 6, 2000, No. 383, § 3.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-51/8074/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074)›§ 8074 - Payment of medical services
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 51 - Prohibition of Restricted Use of 9-1-1 Services by Health Plans (§§ 8071 — 8074) › § 8074 - Payment of medical services
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Every entity subject to the provisions of this chapter shall pay directly to its service providers, with the exception of the co-payment percentages for any necessary medical service that had been provided to an insured or client using the 9-1-1 system due to a medical emergency.
History —Sept. 6, 2000, No. 383, § 4.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8081/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8081 - Adoption and purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8081 - Adoption and purpose
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It is the interest of the Commonwealth of Puerto Rico to accept and adopt the clauses and conditions established in the “Compact for the Interstate Regulation of Insurance Products”, which reads as follows:
The purpose of the present Compact is to promote and protect, through the joint action of and the cooperation between the subscribing states, the interest of the consumers of insurance products, such as annuities, life insurance, and disability and both individual and group long-term care insurance payments. The adoption of this Compact seeks to develop uniform standards among the various states for insurance products covered by the Compact.
The Interstate Insurance Products Regulatory Commission is hereby created as a body charged with developing and implementing uniform standards for the various insurance lines. To achieve the preceding, a central office is established to receive and expeditiously review the insurance products covered by the Compact as well as the advertising related to those products that are introduced by the insurers authorized to operate in one or more of the subscribing states. Another purpose of the former is to expedite the approval of the corresponding products and advertisements introduced that meet the applicable uniform standards.
The adoption of this Compact also seeks to foster the coordination of the regulatory resources and the expertise of the various state insurance departments regarding the establishment of uniform standards and to review the insurance products covered by said provision. To achieve this purpose all those functions consonant with the state regulations pertinent to the insurance business are carried out.
History —Dec. 22, 2005, No. 161, art. 1.1.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8082/
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8082 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8082 - Definitions
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For the purpose of this Compact, the following terms and phrases shall have the meaning expressed below:
(a) Advertisement.— Means any material designed to create public interest in a product or to induce the public to purchase, increase, modify, reinstate, deliver, replace or retain a policy or to take money on loan on account of the same, as defined in the Regulations and Operating Procedures of the Commission.
(b) Statutes.— Means the provisions established by the Commission to govern, direct or control the actions or conduct of the Commission.
(c) Subscribing state.— Means every state that has promulgated legislation pursuant to the present Compact and has not withdrawn pursuant to § 8094(a) of this title or been separated pursuant to § 8094(b) of this title.
(d) Commission.— Means the “Interstate Insurance Products Regulatory Commission”, established through the present Compact.
(e) Commissioner.— Means the main state official insurance regulator, including but not limited to the commissioner, the superintendent, the director or the administrator.
(f) Domiciliary state.— Means the state under which the insurer is incorporated or organized or in the case of a foreign insurer the state in which it is incorporated or organized.
(g) Insurer.— Means any entity authorized to by the state to execute insurance contracts in the insurance lines covered by this chapter.
(h) Member.— Means the person designated by the subscribing state as its representative before the Commission or the person designated by him/her.
(i) Non-subscribing state.— Means any state which by the date of approval of this act is not a subscribing state.
(j) Operating procedures.— Means the procedures promulgated by the Commission to implement a rule, a uniform standard or the provisions of the present Compact.
(k) Product.— Means the policy or insurance contract document including any application, endorsement or related form attached to said policy or contract and which becomes part of the same, as well as any evidence of coverage or certificate regarding an individual or group insurance product, be it annuity, life insurance, disability or long-term care payments which the insurer is authorized to issue.
(l) Regulation.— Means a statement promulgated by the Commission, of general or specific application, effective as of a specific date, including the uniform standards developed pursuant to § 8087 of this title for the purpose of implementing, interpreting or establishing the rights or the policies or describe the requirements regarding the organization, the procedures or the business practices established by the Commission which shall have the force of law in the subscribing states.
(m) State.— Means a state or territory of the United States of America, the District of Columbia and the Commonwealth of Puerto Rico.
(n) Third party intermediary.— Means an entity that introduces an insurance product with the Commission on behalf of an insurer.
(o) Uniform standard.— Means a standard adopted by the Commission for a line of insurance products pursuant with § 8087 of this title which shall include all the requirements for the products as a whole; Provided, That every uniform standard shall be understood to prohibit provisions that may be explicit or implicit, incongruent, deceitful or ambiguous in the products and that the manner in which the product is presented to the public shall not be unfair, onerous or contrary to the public policy as determined by the Commission.
History —Dec. 22, 2005, No. 161, art. 1.2.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8083/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8083 - Interstate Commission
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8083 - Interstate Commission
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The subscribing states hereby create and establish an entity known as the “Interstate Insurance Products Regulatory Commission”. Pursuant to § 8084 of this title, the Commission shall have the power to develop uniform standards for the product lines, to receive and make an expeditious review of the products introduced to said Commission and approve the products introduced that meet the applicable uniform standards; Provided, That the Commission shall not be the only entity in charge of receiving and reviewing the insurance products introduced. No provision of this section shall constitute a hindrance to the introduction of a product by an insurer in any state in which the former is authorized to engage in the insurance business. Said introduction shall be subject to the laws of the state in which the introduction is made.
The Commission is a corporate non profit entity independent and distinguishable from each of the subscribing states. The Commission shall have exclusive liability over its obligations, except as otherwise provided in the present Compact.
The proper forum for initiating judicial actions against the Commission or initiated by the latter, shall be the court of the jurisdiction corresponding to the seat of the Commission.
History —Dec. 22, 2005, No. 161, art. 1.3.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8084/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8084 - Interstate Commission—Powers and duties
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8084 - Interstate Commission—Powers and duties
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The Commission shall have the following powers and duties:
(a) To promulgate regulations pursuant to § 8087 of this title that shall have the force of law and bind the subscribing states as provided in the present Compact.
(b) To establish regulations and uniform standards for the products covered by the present Compact and their publicity; these shall have the force of law and bind the subscribing states only concerning the products introduced at the Commission; Provided, That the subscribing states shall be entitled to being excluded from said standard pursuant to § 8087 of this title. All standards established by the Commission for long-term care insurance products may offer greater protection to the consumers, but not less than the protection provided by the “Long-term Care Insurance Model Act” and the “Long-term Care Insurance Model Regulation of the National Association of Insurance Commissioners” (N.A.I.C.), respectively, adopted as of the year 2001. The Commission shall evaluate whether according to the subsequent amendments introduced to the “Long-term Care Insurance Model Act” and the “Long-term Care Insurance Model Regulation” of the N.A.I.C. it is necessary to amend the standards introduced by the Commission for long-term care insurance products.
(c) To receive, review and expeditiously approve the products and rates introduced at the Commission for disability compensation and long-term care insurance products according to the applicable uniform standard. Said approval shall have full force of law and bind the subscribing states.
(d) To receive and expeditiously approve all publicity material that meets the applicable uniform standard related to long-term care insurance products for which the Commission has adopted standards. The Commission shall be authorized to demand that the insurer present the totality or part of its publicity material for its review or approval as regards the products covered by the present Compact, besides the long-term insurance products. Should the Commission determine that the product is of such a nature that the publicity material related to said product might tend to deceive the citizenry, said material must be approved prior to its being used. The actions of the Commission shall have the force of law and bind the subscribing states.
(e) To regulate and designate the publicity products and material subject to a certification process conducted by those that issue said products and materials without the need for the prior approval of the Commission.
(f) To promulgate operating procedures pursuant to § 8087 of this title; these shall be of an obligatory nature with regard to the subscribing states.
(g) To initiate judicial actions on behalf of the Commission; Provided, That the active legitimacy of the state insurance commissioners shall not be affected to initiate suits or be sued pursuant to the applicable laws.
(h) To issue summons for appearance and witness testimonies and the introduction of evidence.
(i) To establish and maintain offices.
(j) To purchase and maintain insurance and bonds.
(k) To borrow, accept and contract personnel services, including but not limited to, employees of the subscribing state.
(l) To contract employees, professionals and specialists, select and appoint officers, fix their compensation, define their duties and grant them the suitable authority to implement the purposes of the present Compact, as well as to determine their qualification; establish the personnel standards of the Commission and the programs related to conflicts of interest, salary schedules and personnel qualifications, among other matters.
(m) To accept any donations and grants of money, equipment, supplies, materials and services and receive, use and dispose of the same; Provided, That the Commission shall avoid the appearance of irregularities.
(n) To lease, purchase and accept suitable donations of real, personal or mixed property and possess, own, improve or use the same; Provided, That the Commission shall avoid the appearance of irregularities.
(o) To sell, transfer, mortgage, assign, rent, exchange, abandon or otherwise dispose of any real, personal or mixed property.
(p) To pay the introduction fees of the subscribing states, as provided in the statutes, regulations or operating procedures.
(q) To ensure compliance by the subscribing states with the regulations, the uniform standards, the operating procedures and the statutes.
(r) To provide for the resolution of controversies among the subscribing states.
(s) To advise the subscribing states on matters related to the domiciled insurers or to those that operate in jurisdictions of the non-subscribing states, consistent with the purposes of this Compact.
(t) To provide advisory and training services to the personnel of the state insurance commissioners who are in charge of the review of the products and to serve as a resource for the state insurance commissioners.
(u) To establish a budget and make disbursements.
(v) To borrow money.
(w) To appoint commissions, including a consulting committee constituted by the state insurance commissioners, the legislators or their representatives, representatives of the insurance industry and of the consumers and any other interested persons that may be designated in the statutes.
(x) To provide and receive information from the agencies and cooperate with said agencies.
(y) [To] adopt a corporate seal.
(z) [To] conduct any other functions needed to achieve the purposes of the present Compact pursuant to state regulations for the insurance business.
History —Dec. 22, 2005, No. 161, art. 1.4.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8085/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8085 - Interstate Commission—Organization and operation
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8085 - Interstate Commission—Organization and operation
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(a) Members, voting and statutes.—
(1) Every subscribing state shall have a member. Every member shall be qualified to serve as such pursuant to the laws of the subscribing state. Any member may be discharged or suspended from office pursuant to the laws of the state that appointed him/her. Any vacancy that may arise in the Commission shall be filled according to the laws of the subscribing state where the vacancy arose. None of the provisions of this paragraph shall affect the way in which the subscribing state determines the election or appointment and qualifications of its own Insurance Commissioner.
(2) Every member shall be entitled to one vote and have the opportunity of participating in the government of the Commission according to the statutes. However, no action of the Commission regarding the promulgation of any uniform standard shall be effective unless two thirds (2 / 3) of the members vote in its favor.
(3) The Commission shall approve statutes to govern its affairs through the majority vote of its members as necessary and appropriate to achieve the purposes and exercise the powers of the present Compact, which include but are not limited to:
(A) Establish the fiscal year;
(B) establish procedures to appoint and elect its members besides holding meetings of the Administrative Committee;
(C) provide reasonable standards and procedures to furnish information to other committees and establish the procedure for generally or specifically delegating any authority or function of the Commission;
(D) establish procedures to notify, convoke and conduct meetings of the Commission consisting of the majority of the members of the Commission, ensuring that they were duly notified about each meeting and that the citizens were given the right of attending every meeting to protect the public interest, the personal information of the individuals and the privileged information of the insurers, including business secrets. The Commission may meet in private only if the majority of the members vote to hold the meeting partially or totally closed. As soon as possible the Commission shall publish a copy of the number of votes cast in favor of holding a closed meeting containing the name and the vote of every members who exercised his/her right to vote. The votes cast by proxy shall not be considered in this type of meeting;
(E) establish the titles and define the duties of the officers as well as the procedures to elect them;
(F) establish personnel standards and procedures and programs related thereto. Notwithstanding the public service laws, or those of a similar nature of the subscribing state, said statutes shall exclusively govern the personnel policies and programs of the Commission;
(G) provide a mechanism for the close of the operations of the Commission and the disbursement of surplus funds that may exist after paying and/or setting asides reserves for paying all its debts and obligations when the Compact concludes, and
(H) publish its regulations and conserve a copy of the original and a copy of its amendments in each of the agencies or offices of the states which subscribe the Compact.
(b) Administrative Committee, officers and personnel.—
(1) An Administrative Committee shall be established constituted by not more than fourteen (14) members as indicated below:
(A) A member of each of the six (6) subscribing states with the largest volume of premiums for life annuities, disability payments and long-term care insurance products, as indicated in the N.A.I.C. registers for the preceding year;
(B) four (4) members of the subscribing states with at least two percent (2%) of the market on the basis of the aforementioned volume of the six (6) subscribing states with the largest volume of premiums, selected by rotation as provided in the statutes, and
(C) four (4) members of the subscribing states with less than two percent (2%) of the market on the basis of the aforementioned volume, each of which shall be selected from each of the four (4) zone regions of the N.A.I.C. as provided in the statutes.
(2) The Administrative Committee shall have the authority and the duties provided in the statutes, which shall include but not be limited to:
(A) Administering all affairs of the Commission according to its purposes;
(B) establishing and overseeing the internal organization structure as well as the proper procedures to enable the Commission to provide for the creation of uniform standards and other regulations for receiving and reviewing the introduction of products, the administrative and technical support functions, the review of decisions related to the denial of a product introduced and the review of cases whereby a subscribing state has opted to be excluded from a certain uniform standard. Provided, That the uniform standard shall not be presented to the subscribing states for their adoption unless it has been approved by two thirds (2 / 3) of the members of the Administrative Committee;
(C) overseeing the offices of the Commission, and
(D) planning, implementing and coordinating activities with other state and federal government entities that promote the goals of the Commission.
(3) The Commission shall annually elect the officers of the Administrative Committee who shall have the authority and duties provided through regulations.
(4) The Administrative Committee shall appoint or contract an executive director, subject to the approval of the Commission under the terms and conditions and with the compensation the Commission may deem appropriate. The executive director shall act as Secretary of the Commission but shall not be a member of the same. The executive director shall contract and supervise the additional personnel the Commission may authorize.
(c) Legislative and Consultancy Committees.—
(1) A legislative committee shall be established constituted by legislators or their representatives to oversee the operations of the Commission and make recommendations. Provided, That the manner in which said officer is to be selected and his/her term of office shall be established through bylaws. Before the Commission establishes any uniform standard, any review of the regulations or any annual budget or before it attends to any other important matter pursuant to the regulations, the Administrative Committee shall consult the legislative committee and submit a report thereto.
(2) The Commission shall establish two (2) consultancy committees, the first constituted by representatives of the consumers independent from the insurance industry and the second constituted by representatives of the insurance industry.
(3) The Commission may establish through regulations other consultancy committees to carry out its functions.
(d) Corporate registers of the Commission.— The Commission shall maintain its books and registers pursuant to the regulatory provisions.
(e) Limited immunity, defense and indemnification.— The members, officers, the executive director and the employees and the representatives of the Commission shall have immunity regarding any legal action, whether in their personal or official capacity, for any claim for damages or loss of property or personal injury or any other civil liability caused by or arising from any action taken or alleged, or error or omission which occurs within their workplace or concerning the duties or responsibilities of the Commission; Provided, That nothing of what has been established shall be construed as protecting any person against suits and/or any liability for damages, losses or bodily injuries caused by the crass, intentional and voluntary prejudicial action of that person.
The Commission shall defend all members, officers, the executive director and the employees or the representatives of the Commission in any civil action directed to imposing some liability arising from any actual or alleged action, or error or omission that occurs as a consequence of their employment, duties or responsibilities in the Commission or in those cases whereby the defendant had reasonable cause to believe that they occurred within his/her workplace, or regarding his/her duties or responsibilities in the Commission; further Provided, That the actual or alleged action, error or omission did not occur as a result of crass negligence or the intentional act on the part of said person.
The Commission shall provide compensation and relieve from all responsibility all members, officers, the executive director and the employees or the representatives of the Commission for any transaction or sentence pronounced against said persons, arising from an action, error or omission, real or alleged, that occurs within the workplace or the duties or responsibilities in the Commission; Provided, That the real or alleged action, error or omission was not the result of crass negligence or intentional improper conduct on the part of said person.
History —Dec. 22, 2005, No. 161, art. 1.5.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8086/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8086 - Interstate Commission—Meetings and acts
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8086 - Interstate Commission—Meetings and acts
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The Commission shall meet and take those actions that are consistent with the provisions of this Compact.
All members of the Commission shall be entitled and have the power to cast their vote to which the subscribing state is entitled and to participate in the work and affairs of the Commission. Every member shall cast his/her vote in person or through the means provided through regulations. The regulations shall provide for the participation of the members at the meetings through a path or other telecommunication or electronic communication means.
The Commission shall meet at least once every calendar year. Additional meetings shall be called as provided in the regulations.
History —Dec. 22, 2005, No. 161, art. 1.6.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8087/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8087 - Regulations and operating procedures; functions and exclusion
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8087 - Regulations and operating procedures; functions and exclusion
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(a) Regulating authority.— The Commission shall establish through regulations uniform standards and operating procedures in order to achieve the purposes of the present Compact. However, should the Commission, while exercising its authority, exceed the scope of this chapter or the powers conferred by the same, said action shall have neither validity nor force of law.
(b) Regulating procedure.— The regulations and operating procedures shall be promulgated pursuant to the criteria established in the “Model State Administrative Procedures Act”, as suitable for the operations of the Commission. Before the Commission adopts any uniform standard it shall notify the corresponding state legislative committee of each subscribing state in writing of its intention to adopt said standard.
(c) Effective date and option for exclusion.— The uniform standards shall take effect ninety (90) days [after] their being promulgated by the Commission or at a later date as determined by the Commission; Provided, however, That the subscribing state may opt to be excluded from any uniform standard. Said option shall be construed as every action directed to refusing to adopt or to participate from any uniform standard that has been promulgated. The regulations and operating procedures and the amendments thereto shall take effect on the date specified in the same.
(d) Procedure for exclusion.— The subscribing states may opt to be excluded from any uniform standard through legislation or regulations adopted by the Insurance Commissioner, pursuant to the Administrative Procedures Act of the subscribing state. Should a subscribing state opt to be excluded from any uniform standard, it shall: (a) notify the Commission in writing at the latest within the next ten (10) days following its promulgation or at the moment the state becomes a subscribing state; and (b) determine that the uniform standard fails to provide reasonable protection to the citizens of said state given the existing conditions of said state.
The Commissioner shall make determinations of fact and conclusions of law based on the preponderance of the evidence in which he/she shall set forth in detail the conditions that exist in the state which justify the deviation from the uniform standard or the determination that the latter fails to reasonably protect the citizens of the state. The Commission shall carefully consider and determine that the conditions that exist in the state and the needs of the citizens of said state are stronger than: (a) the intention of the Legislature of participating in an interstate agreement to establish uniform protection for the consumer at the national level with regard to the products object of the present law and the benefits to be derived from said agreement; and (b) the presumption that the uniform standard adopted by the Commission provides reasonable protection to the consumers of the corresponding product.
However, at the time of approval of the present Compact, the subscribing state may, prospectively, opt to be excluded from all uniform standards related to long term care insurance products by expressly providing said option in the promulgation of the Compact and shall not consider said option as an essential variation in the offer to or acceptance of a state to participate in the present Compact. Said option shall take effect at the time of approval of the present Compact by the subscribing state and shall apply to all uniform standards related to long term care insurance products and those that may be promulgated in the future.
(e) Effect of the option for exclusion.— Should a subscribing state opt to be excluded from a uniform standard, the latter shall remain in force in the state that exercises said option until said option for exclusion is approved as law or until regulations in that respect are adopted.
Once said option for exclusion becomes effective in a subscribing state, the uniform standard shall have no force of law until said law is repealed or the regulations to that effect are invalidated. Should the subscribing state opt to be excluded from a uniform standard after said standard has been in effect in the state, the option for exclusion shall have prospective effect as provided in § 8094 of this title with respect to the exclusion.
(f) Postponement of the execution of the uniform standard.— If the subscribing state has formally initiated the process for exercising the option for exclusion from a uniform standard through regulations and while said process is pending, the subscribing state may request, at least fifteen (15) days prior to the effective date of the uniform standard, that the Commission postpone the effective date. The Commission may grant said postponement if it determines that the option for exclusion is being reasonable transacted through regulations and that said transaction has the probability of being successful. Should the Commission grants the postponement or extend the same, the effective date may be suspended by the postponement or extension of the same for up to ninety (90) days, unless the Commission extends the effective date affirmatively; Provided, That said suspension shall not remain in force for more than one (1) year unless the subscribing state gives evidence of extraordinary circumstances that merit the continuation of the suspension, which shall include but not be limited to: the existence of an objection before the courts that prevents the subscribing state from exercising the option for exclusion. The Commission may declare the suspension without effect if it is notified that the regulating process has concluded.
(g) Judicial review.— Any person may introduce a petition for the judicial review of a rule or procedure not later than the thirty (30) days after the promulgation of the same; Provided, That said petition shall neither delay nor prevent the rule or operating procedure from being effective, except if the court determines that the petitioner has a substantial probability of being successful. The court shall agree to the actions of the Commission pursuant to the applicable laws and shall not decide that the rule or operating procedure is contrary to law if said rule or operating procedure stands for the reasonable exercise of the authority of the Commission.
History —Dec. 22, 2005, No. 161, art. 1.7.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8088/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8088 - Registers and compliance
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8088 - Registers and compliance
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The Commission shall promulgate the rules that establish conditions and procedures according to which the official information and registers are to be disclosed to the public to be examined or copied. The Commission may promulgate additional rules according to which the registers and the information that otherwise would be exempt from being disclosed is to be disclosed to the federal and state agencies, including the law and order agencies, and may execute agreements with said agencies to receive and exchange information or registers subject to the provisions for nondisclosure and confidentiality.
Except for privileged information, registers and data, the laws of the subscribing states relative to confidentiality or nondisclosure shall not exempt the Commissioner of the subscribing state from his/her duty of disclosing any pertinent register, data or information to the Commission; Provided, That said disclosure is not to be construed as constituting an exclusion nor that it shall otherwise affect the confidentiality requirement; and furthermore that except as otherwise provided, the Commission shall not be subject to the laws of the subscribing state relative to the confidentiality or nondisclosure with respect to the registers, data and information in its power. The information of the Commission shall maintain its confidentiality after the same has been delivered to some Commissioner.
The Commission shall oversee the subscribing states to ensure compliance with the duly adopted statutes, regulations, uniform standards and operating procedures. The Commission shall notify the subscribing states in writing about their noncompliance with respect to the statutes, the regulations and the operating procedures. Should the subscribing state that has incurred such noncompliance does not remedy this situation within the term specified in the notice, it shall be understood that the subscribing state is in default as provided in § 8094 of this title.
The Commissioner of any state where the insurer is authorized to operate or is operating an insurance business shall continue to exercise his/her authority for overseeing the regulation of the market in which the activities of the insurer are conducted according to the provisions of the state laws. The following provisions shall govern the actions of the Commission to ensure compliance with said laws.
Regarding the regulation of the market by the Commissioner of publicity products or materials approved or certified by the Commission, no activity of an insurer shall constitute a violation of the provisions, standards or requirements of the Compact, except as provided by the Commission through a final order issued at the request of the Commissioner after notification to the insurer giving the latter the opportunity for attending a hearing before the Commission.
Before a Commissioner can initiate an action before the Commission for the violation of a provision, standard or requirement of the Compact related to the use of publicity material that has not been approved or certified, the Commission or an official or employee authorized by the Commission must authorize said action. Said authorization shall not require that the insurer be notified or that a hearing be granted, or the disclosure of applications for authorization or registers of the action taken by the Commission for attending to said applications.
History —Dec. 22, 2005, No. 161, art. 1.8.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8089/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8089 - Resolution of controversies
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8089 - Resolution of controversies
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At the request of a member, the Commission shall resolve all controversies or matters that may arise between two or more subscribing states as well as among the non-subscribing states. The Commission shall promulgate an operating procedure in order to provide for the resolution of said controversies.
History —Dec. 22, 2005, No. 161, 1.9.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8090/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8090 - Introduction and approval of products
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8090 - Introduction and approval of products
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The insurers and third party intermediaries that promote the approval of a product by the Commission shall introduce said product before the Commission and pay the applicable introduction fees. It shall not be construed that the provisions of this Compact restrict or prevent the insurer from introducing a product with the insurance department of any state in which the insurer is licensed to operate an insurance business. Said introduction shall be subject to the laws of the state in which the introduction is made.
The Commission shall establish suitable processes and procedures for introductions and reviews according to the regulations and operating procedures of the Commission. However, should any provision be construed in an opposite sense, the Commission shall promulgate rules to establish conditions and procedures according to which the Commission shall provide public access to the information related to the introduction of products. In establishing said rules, the Commission shall take into account the interests of the citizens in having access to said information as well as in the protection of personal medical and financial information and the business secrets that may be part of the process for introducing a product or its related information.
Any product approved by the Commission may be sold or introduced in the subscribing states in which the insurer is authorized to operate.
History —Dec. 22, 2005, No. 161, art. 1.10.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8091/
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8091 - Review of the decisions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8091 - Review of the decisions
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Not later than the thirty (30) days after the Commission has notified the disapproval of a publicity product or material introduced before the Commission, the insurer or third party intermediary whose introduction has been disapproved may appeal the determination before a review board appointed by the Commission. The Commission shall promulgate the rules for establishing the procedures for appointing said boards and provide for the notification and celebration of a hearing. Any allegation in the sense that the Commission in disapproving a publicity product or material introduced before the same, has acted arbitrarily, capriciously or abusively regarding its discretion or otherwise illicitly, shall be subject to judicial review.
The Commission shall be authorized to oversee, review and reconsider the publicity products and materials after they are introduced or approved when it determines that the product does not meet with the corresponding uniform standard. The Commission may withdraw or modify its approval after the proper prior notice and the celebration of a hearing, subject to the appeal process provided in this Compact.
History —Dec. 22, 2005, No. 161, art. 1.11.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8092/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8092 - Finances
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8092 - Finances
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The Commission shall pay or provide for the payment of reasonable expenses incurred for its establishment and organization. In order to subsidize the cost of its initial operations, the Commission may accept contributions and other types of subsidies from the National Association of Insurance Commissioners, the subscribing states and other sources. The contributions and other types of subsidies from other sources shall be of such a nature that the independence of the Commission with respect to the performance of its duties shall not be in doubt.
The Commission shall collect introduction fees from any insurer or third party intermediary that introduces a produce before the Commission and its personnel, whose total shall be sufficient to cover the annual budget of the Commission.
The budget for the Commission for the fiscal year shall not be approved until it has been presented and discussed as provided in § 8087 of this title.
The Commission shall be exempt from any taxation in the subscribing states or taxation exercised by these.
The Commission shall not pledge the credit of any subscribing state except if the Commission is given the corresponding legal authority by said subscribing state.
The Commission shall keep an account of all internal revenues, including subsidies and donations as well as of the disbursement of all funds under its control. The internal financial accounts of the Commission shall be subject to the accounting procedures provided in the statutes. The financial accounts and reports, including the internal control systems and procedures of the Commission, shall be audited annually by an independent certified public accountant. At least every three (3) years said accountant shall include an administrative and performance audit of the Commission. The Commission shall present an annual report to the Governor and to the Legislatures of the subscribing states that shall include a report of the independent audit. The internal accounts of the Commission shall not be confidential and all documents must be shared with the Commissioners who subscribe this Compact once these request them; Provided, That only those work documents related to internal or independent audits, to individual personal information and to the confidential information of the insurers, including business secrets, shall remain confidential.
No subscribing state shall be entitled to present a claim for or reclaim the title of any property of the Commission over which the Commission has a vested right nor any of the funds of the Commission possesses pursuant to the provisions of the present Compact.
History —Dec. 22, 2005, No. 161, art. 1.12.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8093/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8093 - Subscribing states, effective date and amendments
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8093 - Subscribing states, effective date and amendments
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Any state shall be eligible to become a subscribing state.
The Compact shall take effect and be obligatory as of the moment in which two (2) subscribing states turn the Compact into law; Provided, That the Commission shall be effective for the purpose of adopting uniform standards for the products introduced to the Commission, for reviewing, approving or disapproving the same if they meet the uniform standards applicable, when twenty-six (26) states have become subscribing states, or as an alternative, through the approval by the states which represent over forty percent (40%) of the volume of premiums for life insurance, annuities, disability payments and long term insurance products based on the N.A.I.C. registers for the preceding year. This shall be effective and obligatory with respect to all other subscribing states when the present Compact becomes law in any of said states.
The Commission may propose amendments to the present Compact to be approved by the subscribing states. No amendment shall become effective nor be compulsory for the Commission or the subscribing states until the subscribing states approve said amendment as law.
History —Dec. 22, 2005, No. 161, art. 1.13.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8094/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8094 - Disaffiliation, default and dissolution
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8094 - Disaffiliation, default and dissolution
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(a) Disaffiliation.— Once the Compact is in effect it shall remain in effect and shall be obligatory in all subscribing states; Provided, That a subscribing state may disaffiliate itself from the Compact through the approval of a law that repeals the statute by which the Compact became law.
The effective date of the disaffiliation shall be the effective date of the repeal. However, the disaffiliation shall not apply to the products introduced that have been approved or are already certified or to the publicity material of said products by the date in which the law through which the disaffiliation took place becomes effective, except through an agreement between the Commission and the disaffiliated state, unless the disaffiliated state revokes the approval as provided in the present Compact.
The Commissioner of the disaffiliating state shall immediately notify the Administrative Committee upon the introduction of the bill to repeal the Compact in the disaffiliating state.
The Commission shall notify all other subscribing states about the filing to repeal this Compact in the disaffiliated state within ten (10) days of having received notice thereof.
The disaffiliated state shall be liable for all obligations, duties and responsibilities incurred [up] to the effective date of disaffiliation, including any obligation whose execution extends beyond the effective date of disaffiliation, except those obligations that may be excused or delivered through a mutual agreement between the Commission and the disaffiliated state. The approval granted by the Commission about the publicity products and materials prior to the date of disaffiliation of the state shall remain in force, except if revoked by said state in the same way the laws of the disaffiliated state authorize the prospective disapproval of publicity products or materials.
Reinstatement after disaffiliation shall take place when the disaffiliated state again approves the Compact.
(b) Default.— Should the Commission determine that a subscribing state has failed to meet (has been in default of) its obligations or responsibilities pursuant to the present Compact, all rights, privileges and benefits shall be suspended after notice and hearing as provided in the regulations, effective to the date the Commission may determine. The grounds for determining whether the state is in default include but are not limited to, (a)[sic] whether the subscribing state has failed to meet its obligations and responsibilities as established in the regulations of the Commission. The Commission shall immediately notify the state in writing about the suspension until noncompliance has been remedied. The Commission shall stipulate the conditions and the term within which noncompliance must be remedied. Should the state fail to remedy the errors within the term established by the Commission, it shall be suspended from the Compact and all its rights, privileges and benefits shall cease as of the effective date of the separation.
The approval of products granted by the Commission or the certification of products made by the party which makes the introduction, or of all materials related to said products that are in effect at the time of separation of the state, shall remain in force as if the state in default had disaffiliated itself voluntarily pursuant to this section.
Reinstatement after the disaffiliation of a subscribing state shall again require approval of the Compact through a law.
(c) Dissolution of the Compact.— The dissolution of the Compact shall occur on the effective date of the disaffiliation or default of the subscribing state that would reduce the number of members of the Compact to a single subscribing state. Upon the dissolution of the present Compact, the same shall be null and shall not have force or effect of law and the operations and the affairs of the Commission shall be concluded and any surplus funds shall be distributed according to the bylaws.
History —Dec. 22, 2005, No. 161, art. 1.14.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8095/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8095 - Separability and construction
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8095 - Separability and construction
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The provisions of the present Compact shall be separable and if it is determined that any phrase, clause or sentence cannot be enforced or is declared unconstitutional by a competent court of any participating state or territory or by the United States, the judgment rendered to that effect shall not affect, prejudice or invalidate the remaining provisions of law. All remaining parts shall have full force and effect.
The provisions of the present Compact shall be construed liberally to achieve their purpose.
History —Dec. 22, 2005, No. 161, art. 1.15.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-2/chapter-52/8096/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 2 - Other Insurances (§§ 8001 — 8096)›Chapter 52 - Insurance Products (§§ 8081 — 8096)›§ 8096 - Obligatory effect of the Compact and other laws
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 2 - Other Insurances (§§ 8001 — 8096) › Chapter 52 - Insurance Products (§§ 8081 — 8096) › § 8096 - Obligatory effect of the Compact and other laws
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(a) Other laws.— Nothing of what is [herein] provided shall prevent compliance with any other law of a participating state which is not inconsistent with this Compact, except as provided in this section.
In relation to the products approved or certified by the Commission, the regulations, the uniform standards and all other requirement of the Commission shall constitute the exclusive provisions applicable to the contents, the approval and the certification of said products. As regards the publicity materials subject to the authority of the Commission, any rule, uniform standards or other requirement of the Commission that governs the contents of the publicity materials shall constitute the exclusive provision which a Commissioner may apply to the contents of said materials. However, no action taken by the Commission shall neither abrogate nor restrict: (a) the access of any person, including the Secretary of Justice and the state courts; (b) the remedies available pursuant to the state laws related to contract noncompliance, civil damages or other laws not specifically related to the contents of the product; or (c) the state laws related to the interpretation of insurance contracts.
All insurance products introduced in the individual states shall be subject to the laws of said states.
(b) Obligatory effect of the Compact.— All regulations and operating procedures promulgated by the Commission shall be of an obligatory nature with respect to the subscribing states.
All agreements between the Commission and the subscribing states shall be of an obligatory nature pursuant to their terms.
At the request of any of the parties in a controversy with respect to the meaning or construction of any action of the Commission and with the prior majority vote of the subscribing states, the Commission may issue consultative opinions with respect to the controversial meaning or construction.
In case any provision of the present Compact exceeds the constitutional limitations imposed on the Legislature of any subscribing state, the obligations, duties, powers or jurisdiction asked to be conferred upon the Commission by said provision shall not have any effect and said obligations, duties, powers or jurisdiction shall remain in the subscribing state and be exercised by the agency of the latter to which said obligations, duties, powers or jurisdiction are delegated by a law in effect when this Compact is in force.
History —Dec. 22, 2005, No. 161, art. 1.16.
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9001 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9001 - Title
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This subtitle constitutes the Puerto Rico Health Insurance Code and may be cited as such.
History —Aug. 29, 2011, No. 194, § 2.010, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9002/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9002 - Declaration of public policy
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9002 - Declaration of public policy
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Guaranteeing the most effective regulation of the health insurance industry, including the regulation of those entities that offer group and individual health plans, is hereby adopted as public policy by the Government of Puerto Rico. As part of this public policy, it is vital to comply with the rules set forth under the Federal Health Reform and implemented through the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. Likewise, in the Commonwealth, it is necessary to gather and standardize to the extent possible, all the legal norms that shall apply to such an important industry, which has experienced an unprecedented growth in the past years, into one new law to be known as the Puerto Rico Health Insurance Code.
The main purpose of the public policy herein adopted is to provide all Puerto Ricans with access to more and better healthcare services and to promote maximum growth and development in this industry.
History —Aug. 29, 2011, No. 194, § 2.020, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9003/1/
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9003 - Definitions (§ 9003)›1
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9003 - Definitions (§ 9003) › 1
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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.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9003/2/
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9003 - Definitions (§ 9003)›2
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9003 - Definitions (§ 9003) › 2
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For purposes of this Code, except in those chapters in which 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 metal 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.
(4) Stepchildren.
(5) 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.
(6) Unemancipated minor whose custody has been awarded to the subscriber.
(7) A person of any age who has been declared incompetent by a court and whose custody has been awarded to the enrollee.
(8) 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.
(9) 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 healthcare service corporation, healthcare service organization, or any other entity providing health benefit, service, or healthcare plans.
(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) Primary care provider.— Means the participating provider selected by the covered person or enrollee or, in its default, by a health insurance organization or issuer, designated to supervise, coordinate, or provide initial care or continuing care to the covered person or enrollee.
(v) 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.
(w) 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.
(x) Health Insurance Code Regulations.— Refer to the rules or regulations adopted by the Commissioner pursuant to any provision of this Code.
(y) Healthcare services or medical services.— Mean services for the diagnosis, prevention, treatment, cure, or relief of a chronic health condition, illness, injury, or disease.
(z) Emergency services.— Mean healthcare services furnished or required to treat an emergency medical condition.
(aa) Subscriber.— Means an individual covered by a health plan issued by a healthcare service organization.
(bb) 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.
(cc) Essential health benefits.— Means the services identified as “essential health benefits” in Section 1302(b) of Public Law 111-148, known as the “Patient Protection and Affordable Care Act”, as amended by Public Law 111-152, known as the “Health Care and Education Reconciliation Act”, as well as with federal and local regulations adopted thereunder.
Notice This section has more than one version with varying effective dates. Second of two versions of this section.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9004/
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9004 - Insurance Code of Puerto Rico
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9004 - Insurance Code of Puerto Rico
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The provisions of the Insurance Code of Puerto Rico shall apply to health insurance plans and entities regulated by this Code inasmuch as they are not inconsistent with the provisions thereof.
Nothing provided in this Code shall be construed to amend or repeal the laws, regulations, or procedures administered by the Patients” Advocate Office and the Puerto Rico Health Insurance Administration (ASES) in accordance with their enabling acts.
Any issuer that enters into contracts with ASES to offer, market, or administer the Puerto Rico Government Plan (Mi Salud) shall meet the requirements and comply with the legal, regulatory, and contractual provisions established by ASES, except for matters related to the authorization or license required to engage in the insurance business in Puerto Rico, and those pertaining to financial solvency to which the Puerto Rico Insurance Code and this Code shall apply.
History —Aug. 29, 2011, No. 194, § 2.040; Sept. 29, 2012, No. 290, § 1.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9005/
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9005 - Conformity to federal laws
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9005 - Conformity to federal laws
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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.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9006/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9006 - Powers and duties of the Commissioner
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9006 - Powers and duties of the Commissioner
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According to this Code, the Commissioner shall have the powers, authorities, and duties vested in him/her by virtue thereof and, also, the powers, authorities, and duties established in the Insurance Code of Puerto Rico.
History —Aug. 29, 2011, No. 194, § 2.060, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9007/
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9007 - Severability
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9007 - Severability
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If any provision of this Code or the applicability thereof to any person or circumstance were held to be void or invalid by a court with jurisdiction and competence, such holding shall not affect the validity of all other provisions of the Code or their applicability to persons or circumstances other than those that were held to be void or invalid.
History —Aug. 29, 2011, No. 194, § 2.070, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-100/9008/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 100 - General Provisions (§§ 9001 — 9008)›§ 9008 - Sanctions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 100 - General Provisions (§§ 9001 — 9008) › § 9008 - Sanctions
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Any violations of the provisions of this Code or the rules or regulations promulgated thereunder for which a sanction or penalty has not been expressly prescribed shall be subject to an administrative fine of not less than five hundred dollars ($500) or more than ten thousand dollars ($10,000) for each violation.
History —Aug. 29, 2011, No. 194, § 2.080, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9041/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9041 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9041 - Title
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This chapter shall be known and may be cited as the chapter on Prescription Drug Management.
History —Aug. 29, 2011, No. 194, § 4.010, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9042/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9042 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9042 - Purpose
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The purpose of this chapter is to provide standards for the development, maintenance, and management of prescription drug formularies and other procedures as part of the prescription drug benefits established by health insurance organizations or issuers that provide such services.
History —Aug. 29, 2011, No. 194, § 4.020, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9043/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9043 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9043 - Definitions
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For purposes of this chapter:
(a) Prior authorization.— Means the process of obtaining prior approval from a health insurance organization or issuer, required under the terms of a health plan, for coverage of a prescription drug.
(b) Pharmacy and Therapeutics Committee.— Means a committee or equivalent body that is comprised of individuals who are either employed by or under contract with the health insurance organization or issuer, which shall be composed of an odd number of members. The members of the Pharmacy and Therapeutics Committee shall be healthcare professionals, such as physicians and pharmacists, who have knowledge and expertise in:
(1) Clinically appropriate prescribing, dispensing, and monitoring of outpatient prescription drugs, and
(2) drug use review, evaluation, and intervention.
If there were any representatives of the pharmacy benefits manager, the health insurance organization, or issuer among the members of the Pharmacy and Therapeutics Committee, the same shall only contribute with operations and logistic considerations, but shall not vote on issues related to adding or excluding prescription drugs from the formulary.
(c) Clinical review criteria.— Mean the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a healthcare organization or issuer to determine medical necessity and appropriateness of healthcare services.
(d) Medical or scientific evidence.— Means evidence found in any of the following sources:
(1) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts.
(2) Peer-reviewed medical literature, including literature related to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meets the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medica (EMBASE).
(3) Medical journals recognized by the Secretary of Health and Human Services of the United States Government under the Federal Social Security Act.
(4) The following standard reference compendia:
(A) The American Hospital Formulary Service-Drug Information.
(B) Drug Facts and Comparisons.
(C) The American Dental Association Accepted Dental Therapeutics.
(D) The United States Pharmacopeia-Drug Information.
(5) Findings, studies, or research conducted by or under the auspices of Federal government agencies and federal research institutes recognized in the United States of America, including:
(A) The Agency for Healthcare Research and Quality.
(B) The National Institutes of Health.
(C) The National Cancer Institute.
(D) The National Academy of Sciences.
(E) The Centers for Medicare and Medicaid Services (CMS).
(F) The Food and Drug Administration (FDA).
(G) Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of healthcare services.
(6) Any other medical or scientific evidence that is comparable to the sources listed in clauses (1)–(5) above.
(e) Categorical exclusion.— Means an express determination by a health plan not to provide coverage for a prescription drug, identifying the same by its scientific or brand name.
(f) Formulary.— Means a list of prescription drugs that has been developed by a health insurance organization or issuer or its designee, which is regularly evaluated to add or exclude prescription drugs, and which the health insurance organization or issuer or its designee references in determining pharmacy coverage.
(g) Prescription drug.— Means a drug that has been approved or regulated and that the Food and Drug Administration (FDA) has allowed to be marketed, and which the laws of Puerto Rico and the United States requires to be dispensed only through a prescription order.
(h) Prescription drug order or Prescription.— Means an order from a licensed, certified or otherwise legally authorized prescriber to a pharmacist for a prescription drug to be dispensed.
(i) Prescriber.— Means any healthcare professional legally authorized to issue prescription drug orders.
(j) Pharmaceutical Benefit Management Procedure or “PBMP” includes any of the following:
(1) A formulary;
(2) dose restrictions and quantity limits;
(3) prior authorization requirements, or
(4) step therapy requirements.
(k) Grievance.— Means a written complaint requesting a remedy submitted by or on behalf of a covered person or enrollee, for the actions or determinations of a health insurance organization or issuer regarding:
(1) The availability, delivery, or quality of healthcare services, including a complaint regarding an adverse determination made pursuant to utilization review;
(2) claims payment, handling, or reimbursement for healthcare services, or
(3) matters pertaining to the contractual relationship between a covered person or enrollee and a health insurance organization or issuer.
(l) Authorized representative.— Means:
(1) A person to whom the covered person or enrollee has given express written consent to represent him/her in requesting a medical exception pursuant to this chapter.
(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 who treats or dispenses prescription drugs to the covered person or enrollee, in order to request a medical exception on the latter's behalf, pursuant to the chapter.
(m) Dose restriction.— Means imposing a restriction on the number of doses of a prescription drug that will be covered during a specific time period.
(1) Dose restriction does not include:
(A) A restriction set forth in the coverage that limits the number of doses of a prescription drug that will be covered during a specific time period; or
(B) a restriction on the number of doses of a prescription drug when it has been withdrawn from the market by the drug's manufacturer or it cannot be supplied.
(n) Generic substitution.— Means the substitution of a generic version of a brand name prescription drug that has the same active ingredients, strength, and intended use as the brand name prescription drug, whose therapeutic equivalence has been recognized by the Food and Drugs Administration (FDA), and is coded as such in the Approved Drug Products with Therapeutic Equivalence Evaluations, better known as the “Orange Book”.
(o) Step therapy.— Means a type of protocol that specifies the sequence in which different prescription drugs for a given medical condition are to be prescribed.
History —Aug. 29, 2011, No. 194, § 4.030, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9044/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9044 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9044 - Applicability and scope
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This chapter shall apply to all health insurance organizations or issuers, or their designees, who provide or administer benefits for outpatient prescription drugs in accordance with the provisions of the health plan, through the use of a formulary or through the application of any other pharmaceutical benefit management procedure.
Nothing in this chapter shall be construed to apply to prescription drugs that are categorically or contractually excluded from a covered person or enrollee's health plan. A provision in the benefit contract that purports to exclude all nonformulary prescription drugs shall not be considered a categorical exclusion for purposes of this chapter.
History —Aug. 29, 2011, No. 194, § 4.040, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9045/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9045 - Requirements for the development, maintenance, and management of prescription drug formular...
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9045 - Requirements for the development, maintenance, and management of prescription drug formularies and other pharmaceutical benefit management procedures
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(a) Each health insurance organization or issuer that provides benefits for prescription drugs and manages such benefit through the use of a formulary or other procedure shall establish one or more Pharmacy and Therapeutics Committees, as considered appropriate by the health insurance organization or issuer, to develop, maintain, and manage such formulary and related procedures as provided in this section. The Pharmacy and Therapeutics Committee shall not participate in the benefit determination process established by the health insurance organization or issuer for the dispensation of prescription drugs.
The health insurance organization or issuer shall ensure that any Pharmacy and Therapeutics Committee establishes policies and disclosure requirements that address potential conflict of interests that the members of the committees may have with developers or manufacturers of prescription drugs. No member of the Pharmacy and Therapeutics Committee may have any relationship or interest, financial or otherwise, with developers or manufacturers of prescription drugs.
(b) The health insurance organization or issuer shall ensure that any Pharmacy and Therapeutics Committee establishes a process in writing to evaluate medical and scientific evidence concerning the safety and effectiveness of prescription drugs, including available comparative information on clinically similar prescription drugs, when deciding what prescription drugs to include on a formulary or bioequivalent and when developing other management processes. The health insurance organization or issuer shall also ensure that the Pharmacy and Therapeutics Committee uses a process for analysis and possible inclusion in the formulary of prescription drugs for off-label use, the effectiveness of which has been proven by medical and scientific evidence to treat other health conditions.
Every Pharmacy and Therapeutics Committee shall maintain documentation of the process required under this subsection and make any records and documents related to the process available, upon request, to the health insurance organization or issuer.
(c) The health insurance organization or issuer shall ensure that every Pharmacy and Therapeutics Committee adopts and follows a written process to enable it to consider the need for and implement appropriate updates and changes to the formulary in a timely manner based on:
(1) Newly available scientific and medical evidence or other information concerning prescription drugs currently listed on the formulary or subject to any other management process, and scientific and medical evidence on newly approved prescription drugs and other prescription drugs not currently listed on the formulary or subject to any other management process, to determine whether a change to the formulary or management process should be made;
(2) if applicable, information received from the health insurance organization or issuer with respect to medical exception requests to enable the Pharmacy and Therapeutics Committee to evaluate whether the prescription drugs currently listed on the formulary or subject to any other management process are meeting the healthcare service needs of covered persons or enrollees, and
(3) information related to the safety and effectiveness of a prescription drug currently listed on the formulary or subject to any other management process, related to clinically similar or bioequivalent prescription drugs not currently listed on the formulary or subject to any other management process, information arising from the health insurance organization or issuer's quality assurance activities, or claims data that was received since the date of the Pharmacy and Therapeutics Committee's most recent review of the prescription drug.
(4) the health insurance organization or issuer shall require the Pharmacy and Therapeutics Committee to evaluate prescription drugs newly approved by the Food and Drug Administration (FDA) within a term that shall not exceed ninety (90) days counted as of the FDA's date of approval. Within a term that shall not exceed ninety (90) days, counted as of the release in the market of the new prescription drug, the Pharmacy and Therapeutics Committee shall issue its determination as to whether or not such prescription drug shall be listed in the formulary.
(d) Subject to this chapter, a health insurance organization or issuer may contract with another person to perform the functions of the Pharmacy and Therapeutic Committee as described in this section. Such health insurance organization or issuer shall answer to the Commissioner for the Pharmacy and Therapeutics Committee's actions, noncompliance with, and violations of this chapter.
History —Aug. 29, 2011, No. 194, § 4.050, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9046/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9046 - Information to prescribers, pharmacies, covered persons or enrollees, and prospective cover...
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9046 - Information to prescribers, pharmacies, covered persons or enrollees, and prospective covered persons or enrollees
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(a) Health insurance organizations or issuers or pharmacy benefit managers shall meet the following requirements:
(1) Every health insurance organization or issuer or pharmacy benefits manager shall maintain and make available to covered persons or enrollees, prescribers and pharmacies, or those providing healthcare services to:
(A) Its formulary (list of prescription drugs) by therapeutic category and, in the case of pharmacy benefit managers, the list of prices known as “maximum allowable cost”;
(B) information indicating which prescription drugs, if any, are subject to a management procedure that has been developed and maintained pursuant to this chapter, and
(C) information on how and what written documentation is required to be submitted in order for covered persons or enrollees, or their authorized representatives, to file a request under the health insurance organization or issuer’s medical exceptions process established pursuant to § 9047 of this title
(2) A health insurance organization or issuer shall only make, during the term of the policy, certificate, or contract, changes in the formulary, or other prescription drugs management process if such change is being made for safety reasons or because the prescription drug cannot be supplied or has been withdrawn from the market by the drug’s manufacturer, or if such change entails the inclusion of prescription drugs in the formulary. To such effects, not later than the effective date of the change, the health insurance organization or issuer shall provide notice of, or shall entrust a third party to provide notice of that change to:
(A) All covered persons or enrollees, and
(B) participating pharmacies only if such change entails the inclusion of prescription drugs in the formulary. In such case, the issuer shall provide notice thereof thirty (30) days before the effective date of inclusion.
History —Aug. 29, 2011, No. 194, § 4.060, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 3, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9047/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9047 - Medical exceptions approval process requirements and procedures
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9047 - Medical exceptions approval process requirements and procedures
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(a) If the health insurance organization or issuer that provides prescription drug benefits and manages this benefit through the use of a formulary or through the application of a dose restriction that causes a prescription for a particular drug not to be covered for the number of doses prescribed, or step therapy requirement that causes a particular drug not be covered until the requirements of that management process have been met, the health insurance organization or issuer shall establish and maintain a medical exceptions process that allows covered persons or enrollee, or their authorized representatives, to request approval for:
(1) A prescription drug that is not covered based on the formulary;
(2) continued coverage of a particular prescription drug whose coverage the health insurance organization or issuer shall discontinue from the formulary for reasons other than safety or because the prescription drug cannot be supplied or has been withdrawn from the market by the drug's manufacturer, or
(3) an exception to a management process that causes a prescription drug to not be covered until the step therapy requirement is satisfied or not be covered at the prescribed number of doses.
(b)
(1) A covered person or enrollee, or his/her authorized representative, may only file a written request under this section if the prescribing provider has determined that the requested prescription drug is medically necessary to treat the covered person or enrollee's disease or medical condition because:
(A) There is no prescription drug listed on the formulary that is a clinically acceptable alternative to treat the covered person or enrollee's disease or medical condition.
(B) The prescription drug alternative listed on the formulary or required in accordance with step therapy requirements:
(i) Has been ineffective in the treatment of the covered person or enrollee's disease or medical condition or, based on clinical, medical, and scientific evidence and the known relevant physical or mental characteristics of the covered person or enrollee and known characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or
(ii) has caused or, based on clinical, medical, and scientific evidence, is likely to cause an adverse reaction or other harm to the covered person or enrollee, or
(iii) the covered person or enrollee was at the top level of a step therapy under another health plan, so that it would be unreasonable to start in a lower step therapy level.
(C) The doses available under a dose restriction for the prescription drug has been ineffective in the treatment of the covered person or enrollee's disease or medical condition or, based on clinical, medical, and scientific evidence and the known relevant physical or mental characteristics of the covered person or enrollee and known characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug's effectiveness or patient compliance.
(2)
(A) The health insurance organization or issuer may require the covered person or enrollee, or his/her authorized representative, to provide a written certification from the prescribing provider of the determination made under clause (1).
(B) The health insurance organization or issuer may require the written certification to include only the following information:
(i) The name, group or contract number, subscriber number.
(ii) Patient history.
(iii) The primary diagnosis related to the requested prescription drug that is the subject of the medical exception request.
(iv) The reason:
(I) Why the formulary drug is not acceptable for that particular patient;
(II) if the medical exception request involves a step therapy requirement, why the prescription drug required is not acceptable for that particular patient, or
(III) if the medical exception request involves a dose restriction, why the available number of doses for the prescription drug is not acceptable for that particular patient.
(v) The reason why the prescription drug that is the subject of the medical exception request is needed for the patient or, if the medical exception request involves a dose restriction, why an exception to the dose restriction is needed for that particular patient.
(c)
(1) Upon receipt of a medical exception request made pursuant to this section, the health insurance organization or issuer shall ensure that the request is reviewed by appropriate healthcare professionals who, depending on the health condition for which the medical exception is requested, in reaching a decision on the request, shall take into account the specific facts and circumstances that apply to the covered person or enrollee for whom the request has been made using documented clinical review criteria that:
(A) Are based on solid clinical, medical, and scientific evidence, and
(B) if available, appropriate practice guidelines, which may include generally accepted practice guidelines, evidence-based practice guidelines, practice guidelines developed by the health insurance organization or issuer's Pharmacy and Therapeutics Committee, or any other practice guidelines developed by the federal government or by national or professional medical or pharmacist societies, boards, and associations.
(2) The healthcare professionals designated by the health insurance organization or issuer to review the medical exceptions request shall ensure that the decision reached on such request is consistent with the benefits and exclusions under the covered person or enrollee's health plan. The healthcare professionals designated to review medical exception requests shall have experience in the management of prescription drugs. Such determinations shall be duly stated in a report, which shall include the qualifications of the healthcare professionals who made such determination.
(d)
(1) The medical exceptions process under this section shall require the health insurance organization or issuer to make a decision on a request made and provide notice of the decision to the covered person or enrollee, or his/her authorized representative, as quickly as the covered person or enrollee’s particular medical condition requires, but in no event later than seventy-two (72) hours after the date of receipt of the request, or the date of receipt of the certification, if required by the health insurance organization or issuer pursuant to subsection (b)(2), whichever is later. In the case of controlled drugs, such term shall not exceed thirty-six (36) hours.
(2)
(A) If the health insurance organization or issuer fails to make a decision on the request and provide notice of the decision within the aforementioned time:
(i) The covered person or enrollee shall be entitled, for a term of thirty (30) days, to the supply of the prescription drug that is the subject of the request and, as the supply is requested or prescribed, in the case of step therapy, for the term established in the coverage.
(ii) the health insurance organization or issuer shall make a decision on the medical exception request prior to the covered person or enrollee's completion of the supply.
(B) If the health insurance organization or issuer fails to make a decision on the medical exception request and provides notice of such decision prior to the covered person or enrollee's completion of the supply, the health insurance organization or issuer shall maintain coverage on the same terms on an ongoing basis, as long as the prescription drug continues to be prescribed for that covered person or enrollee and is considered safe for the treatment of his/her disease or medical condition, unless the applicable benefit limits have been exhausted.
(e)
(1) Whenever a medical exception request made under this section is approved, the health insurance organization or issuer shall provide coverage for the prescription drug that is the subject of the request and not require the covered person or enrollee to request approval under this section for a refill or anew prescription to continue using the prescription drug after the refills for the initial prescription have been exhausted. All of the foregoing shall be subject to the terms of the prescription drugs coverage under the health plan, provided:
(A) That the covered person or enrollee's prescribing provider continues to prescribe such prescription drug to treat the same disease or medical condition, and
(B) the prescription drug continues to be considered safe for treating the covered person or enrollee's disease or medical condition.
(2) The health insurance organization or issuer shall not establish a special formulary tier, co-payment, or other cost-sharing requirement that is applicable only to prescription drugs approved through medical exception requests.
(f)
(1) Any denial of a medical exception request made by a health insurance organization or issuer:
(A) Shall be notified to the covered person or enrollee or, if applicable, to his/her authorized representative, in writing or electronically, if the covered person or enrollee has agreed to receive information in this manner;
(B) shall be notified electronically to the prescribing provider or, upon request, in writing, and
(C) may be appealed by filing a grievance pursuant to the chapter on Health Insurance Organization or Issuer Grievance Procedures of this Code.
(2) The denial shall, in a manner that is comprehensible to the covered person or enrollee or, if applicable, his/her authorized representative, set forth:
(A) The specific reasons for the denial;
(B) a reference to the evidence or documentation, including the clinical review criteria practice guidelines, and clinical, medical, and scientific evidence considered in reaching the decision to deny the request;
(C) instructions for requesting a written statement of the clinical, medical, or scientific rationale for the denial, and
(D) a description of the process and procedures that must be followed for filing a grievance to appeal the denial pursuant to the chapter on Health Insurance Organization or Issuer Grievance Procedures of this Code, including anytime limits applicable to those procedures.
(g) A health insurance organization or issuer shall not be required to establish a medical exception request process or to comply with the provisions of subsections (b), (c), (d), (e)(1), and (f) of this section if such health insurance organization or issuer:
(1) Has an expedited utilization review process as provided in the chapter on Utilization Review and Benefit Determination of this Code, and
(2) allows covered persons or enrollees, or their authorized representatives, to use this process to seek approval for coverage of a prescription drug that is not covered because of formulary or other management process.
(h) This section shall be construed to allow a covered person or enrollee to use the medical exceptions process set forth herein to request coverage for a prescription drug that is categorically included from coverage under the covered person or enrollee’s health plan.
History —Aug. 29, 2011, No. 194, § 4.070, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 4, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9048/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9048 - Record keeping and reporting requirements
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9048 - Record keeping and reporting requirements
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(a) Each health insurance organization or issuer shall maintain sufficient written or electronic records to demonstrate compliance with this chapter, including records documenting the process for making decisions on formularies and other prescription drug management processes and records documenting the application of the medical exception request process. The records shall be maintained for a period of three (3) years or until the completion of the health insurance organization or issuer's next market conduct examination, whichever is later, and shall be made available to the Commissioner upon request.
(b) Each health insurance organization or issuer shall maintain data on and make available to the Commissioner upon request the following information with respect to medical exception requests:
(1) The total number of medical exception requests;
(2) from the total number of medical exception requests provided under clause (1):
(A) The number of requests made for coverage of a nonformulary prescription drug;
(B) the number of requests made for continuing coverage of a prescription drug that the health insurance organization or issuer was discontinuing from coverage on the formulary for reasons other than safety or because the drug cannot be supplied or has been withdrawn from the market by the drug's manufacturer, and
(C) the number of requests made for an exception to a management process that subjects a prescription drug to dose restrictions or step therapy requirements;
(3) the number of medical exceptions requests approved and denied, and
(4) any other information that the Commissioner may request.
History —Aug. 29, 2011, No. 194, § 4.080, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9049/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9049 - Oversight and contracting responsibilities
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9049 - Oversight and contracting responsibilities
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(a) A health insurance organization or issuer shall be responsible for the oversight of all activities carried out under this chapter and for ensuring that all the requirements thereof and applicable regulations are met.
(b) If a health insurance organization or issuer contracts with another person to carry out activities required under this chapter or applicable regulations, the Commissioner shall hold the health insurance organization or issuer responsible for the oversight of the activities of the contracted person and for ensuring that the requirements of this chapter and applicable regulations with respect to such activity are met.
History —Aug. 29, 2011, No. 194, § 4.090, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9050/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9050 - Disclosure requirements
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9050 - Disclosure requirements
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(a) Each health insurance organization or issuer that uses a formulary or any other prescription drug management process shall, in the policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other document provided to a covered person or enrollee;
(1) Disclose the existence of the formulary and any other management processes and the fact that there may be other plan restrictions or requirements that may affect the specific prescription drugs that will be covered;
(2) describe the medical exception process that may be used to request coverage of nonformulary prescription drugs or to obtain an exception to dose restriction or step therapy requirements, and
(3) describe the process for filing a grievance, as set forth in the chapter on Health Insurance Organization or Issuer Grievance Procedure of this Code, to appeal a denial of a medical exception request.
(b) The policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other document provided to covered persons or enrollees shall explain, in layperson's terms, the information on the health insurance organization or issuer's formulary and each prescription drug management process. Such explanation shall also state that the health insurance organization or issuer shall provide covered persons or enrollees with a copy of the formulary and information about which prescription drugs are subject to a management process.
History —Aug. 29, 2011, No. 194, § 4.100, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9051/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9051 - Incentive or bonus programs
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9051 - Incentive or bonus programs
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(a) No pharmacy, pharmacy benefit manager (PBM), drug manufacturer or distributor, or health insurance organization or issuer shall encourage the practice or participate in incentives programs, or bonus programs or similar transactions directed to healthcare professionals in order to influence them, directly or indirectly, to write prescriptions, prescribe, dispense, or exchange certain bioequivalent drugs for a brand-name drug or vice versa.
(b) Healthcare professionals are hereby banned from receiving or participating in incentives or bonus programs, or other similar transactions, sponsored by a pharmacy, pharmacy benefit manager (PBM), drug manufacturer or distributor, or health insurance organization or issuer in order to influence healthcare professionals, directly or indirectly, to write prescriptions, prescribe, dispense, or exchange certain bioequivalent drugs for a brand-name drug or vice versa.
(c) Notwithstanding subsections (a) and (b) of this section, there shall be allowed the establishment of incentives or bonus programs, or other similar transactions based on the positive results achieved in the management or control of the clinical or health condition of covered persons or enrollees, in accordance with healthcare quality standards established by national organizations devoted to improve results in healthcare, such as the Healthcare Effectiveness Data and Information Set. These programs shall be implemented for the purpose of improving and obtaining optimum results in healthcare management and must meet the parameters that allow sufficient time to identify patterns in the results of the management or control of the clinical or health condition of covered persons or enrollees.
The persons or entities that establish incentives or bonus programs, or other similar transactions, shall submit them to the Commissioner within ninety (90) days before the effective date of such programs, so that the Commissioner may evaluate and approve the same in accordance with the provisions set forth herein. The Commissioner shall prescribe by regulations the criteria to be used to evaluate such programs. Such criteria shall take into account the healthcare quality standards established by the national organizations devoted to improve results in health care, such as the Healthcare Effectiveness Data and Information Set.
(d) The Commissioner may establish those rules and regulations deemed necessary to implement the provisions of this section.
(e) Any person who violates the provisions of this section, in addition to any other penalty established in this Code or the laws of the Government of Puerto Rico, shall be subject to a fine in an amount equal to three times the amount received or granted on account of incentives or bonuses.
History —Aug. 29, 2011, No. 194, § 4.110, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9052/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 102 - Prescription Drug Management (§§ 9041 — 9052)›§ 9052 - Maintenance drugs
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 102 - Prescription Drug Management (§§ 9041 — 9052) › § 9052 - Maintenance drugs
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(a) When the history of the covered person or enrollee so requires, insofar as it does not jeopardize the patient's health, and at the discretion of the healthcare provider, such healthcare provider may prescribe refills for maintenance drugs up to a term that shall not exceed one hundred eighty (180) days, subject to the limitations of the healthplan's coverage.
History —Aug. 29, 2011, No. 194, § 4.120, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9081/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9081 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9081 - Title
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This chapter shall be known and may be cited as the chapter on Health Insurance Organizations or Issuers Claim Audit.
History —Aug. 29, 2011, No. 194, § 6.010, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9082/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9082 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9082 - Purpose
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The purpose of this chapter is to provide for the standardization of claim audits of bills for healthcare services presented to health insurance organizations or issuers, third party administrators, or any other health plans. Such audits shall be carried out to determine whether data in a healthcare record of a provider is supported by services listed on the claim for payment of an enrollee or a provider. It is also intended to alleviate the potential conflict of the audit with medical uses of the health record and to reduce the cost entailed by unnecessary audits.
History —Aug. 29, 2011, No. 194, § 6.020, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9083/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9083 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9083 - Definitions
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For purposes of this chapter:
(a) Qualified claim auditor.— Means a person employed or hired by a health insurance organization or issuer that is recognized as competent to perform or coordinate claim audits and that abides by policies and procedures geared to protect the confidentiality and properly manage all patient information in his/her possession.
(b) Claim audit.— Means a process to determine whether data in a claimant’s clinical record documents healthcare services listed on a claim for payment submitted to a health insurance organization or issuer. Claim audit does not mean a review of the medical necessity of the services provided, or the reasonableness of charges for the services.
(c) Overcharges or unsupported charges.— Means the volume of services indicated on a claim exceeds the total volume identified in the provider’s medical documentation.
(d) Unbilled charges.— Means charges or services provided for and not billed.
(e) Underbilled charges.— Means the volume of services indicated on a claim is less than the volume identified in the provider’s documentation.
(f) Ambulatory surgical center.— Means an establishment with an organized medical staff of physicians, with permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures. Such centers provide continuous physician services and registered nursing services whenever a patient is in the center. An ambulatory surgical center does not provide services for patients to stay overnight, but provide the following services whenever a patient is in the center:
(1) Drug services as needed for medical operations performed;
(2) provisions for physical and emotional well-being of patients;
(3) emergency services;
(4) administrative structure, and
(5) administrative, statistical, and medical records.
(g) Clinical record.— Means a longitudinal and chronological compilation composed of the demographic information and physical and/or behavioral mental health of the patient, family health history, if required and/or provided by the patient, which is completed, documented and kept under the custody of the healthcare service provider, and originated and registered electronically, on paper, or both. A patient’s clinical record includes, but is not limited to medical history, diagnoses, prescription drug history, allergy, notes on progress written by the healthcare provider, treatments, results of diagnostic tests ordered (clinical laboratory tests, x-rays, nuclear medicine tests, imaging, ultrasounds, among others) and may include dental impressions. The term clinical record shall be applied to the record generated on the course of providing healthcare services by a provider, and is subject to the protection of privacy, confidentiality, and security of federal and state regulations. This term shall also include the medical record.
(h) Provider.— Means healthcare professional or healthcare facility duly authorized to render or provide healthcare services.
(i) Final claim.— Means the final itemized bill from a provider detailing all the charges for which the provider is seeking payment.
(j) Claimant.— Means a covered person or enrollee under a health plan who has received healthcare services, the costs of which are submitted to a health insurance organization or issuer for payment, either by the claimant or by another on the claimant’s behalf.
History —Aug. 29, 2011, No. 194, § 6.030, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 5, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9084/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9084 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9084 - Applicability and scope
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This chapter shall apply to all health insurance organizations or issuers. The provider accepting assignment of benefits of a covered person or enrollee shall be responsible for the billing process and the results of the claim audits whether conducted by an employee or by contract with another firm. The provider and health insurance organization or issuer shall:
(a) Supervise the process to ensure that the audit is conducted in accordance with the requirements of this chapter;
(b) be aware of the actions being undertaken by the auditor in connection with the claim audit, and
(c) take prompt remedial action if inappropriate behavior by the auditor, the provider, or the person he/she designates as audit coordinator is discovered.
History —Aug. 29, 2011, No. 194, § 6.040, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 6, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9085/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9085 - Qualifications of auditors and provider audit coordinators
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9085 - Qualifications of auditors and provider audit coordinators
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(a) Claim auditors and provider audit coordinators shall have appropriate knowledge, experience, and expertise in the field of healthcare including, but not limited to, the following areas:
(1) Format and content of the health record as well as other forms of medical and clinical documentation;
(2) generally accepted auditing principles and practices as they apply to claim audits;
(3) billing claims forms in effect in the health insurance industry and billing procedures;
(4) all Commonwealth and federal regulations concerning the use, disclosure and confidentiality of patient records;
(5) specific critical care units, specialty area, and ancillary units involved in a particular audit, and
(6) Medical terminology and coding under updated codes, including ICD-10, CPT, and HCPCS, and as these may be reviewed and updated in the future.
(b) If a provider or health insurance organization or issuer finds that audit personnel do not meet these qualifications shall immediately contact the auditor’s firm or sponsoring party.
(c) Audit personnel shall conduct themselves in a professional manner and adhere to ethical standards and confidentiality requirements, and shall remain objective. They shall be required to completely document their findings and problems.
(d) All unsupported, unbilled or underbilled charges identified in the course of an audit shall be documented in the audit report by the auditor.
(e) Individual audit personnel shall not be placed in a situation through their remuneration, benefits, fees or other instructions that would call their findings into question. Compensation of audit personnel shall be structured so that it does not create incentives to produce questionable audit findings. Providers or health insurance organizations or issuers that encounter an individual who appears to have a conflict of interest shall contact the appropriate officers of the organization conducting the audit.
History —Aug. 29, 2011, No. 194, § 6.050, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 7, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9086/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9086 - Notice of audit
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9086 - Notice of audit
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(a) Health insurance organizations or issuers and providers shall make every effort to resolve claim inquiries directly. The name, contact telephone number, and fax number of each representative of the health insurance organization or issuer or the provider shall be exchanged no later than at the time of billing for a provider and the point of first inquiry by a health insurance organization or issuer.
(b) If a satisfactory resolution of the questions surrounding the bill is not achieved by the representatives of the health insurance organization or issuer and the provider, then a full audit process may be initiated by the health insurance organization or issuer.
(c) Claim audits may require documentation from or review of a patient’s clinical record and other similar medical or clinical documentation. Clinical records exist primarily to ensure continuity of care for a patient. Therefore, the use of a patient’s record for an audit must be secondary to its use in patient care.
(d) All health insurance organization or issuer claim audits shall begin with a notification to the provider of the intent to audit. Notification to the provider by the qualified claim auditor shall occur within six (6) months following receipt of the final claim for payment by the health insurance organization or issuer. Once notified, the provider shall respond to the qualified claim auditor within thirty (30) calendar days with a schedule for the conduct of the audit. The qualified auditor shall complete the audit within thirty-six (36) months of receipt of the final claim by the health insurance organization or issuer. Each party shall make reasonable provisions to accommodate circumstances in which the schedule specified cannot be met by the other party. The health insurance organization or issuer shall not request nor accept audits after thirty-six (36) months from the date of receipt of the final claim. Provided, That it shall not be construed that the thirty-six (36) month term provided to complete the audit shall render ineffective shorter terms that have been agreed on for the same purposes under a contract. For purposes of the scope of the audit, the practice of extrapolating or projecting overpayment recovery from providers by the health insurance organizations, issuers, or third parties contracted by them in audits that find billing errors beyond the audited period is hereby prohibited.
(e) All claim audits shall be conducted on the premises of the provider, except in instances where a provider chooses to allow individual, reasonable requests for off-site audits.
(f) All requests for claim audits, whether by telephone, electronic or written, shall include the following information:
(1) The basis of the health insurance organization or issuer’s intent to conduct an audit on a particular bill or group of bills. When the intent is to audit only specific charges or portions of the bills, this information should be included in the notification;
(2) name of the patient;
(3) admit and discharge dates, if apply;
(4) name of the auditor and the name of the audit firm, if the health insurance organization or issuer has contracted with a third party to conduct the audit;
(5) Clinical record number and the provider’s patient account number, if known, and
(6) whom to contact to discuss the request and scheduled audit.
(g) Providers that cannot accommodate an audit request that conforms to these provisions shall explain, within a term that shall not exceed thirty (30) calendar days, why the request cannot be met. Along with the explanation, providers shall propose a new date to reschedule the audit, which shall not exceed forty (40) days as of the date of the original audit. Auditors shall group audits to increase efficiency whenever possible.
(h) It shall be the responsibility of the provider seeking payment of a claim or reimbursement to notify the auditor prior to the scheduled date of audit, if the auditor shall have problems accessing records. The provider shall be responsible for supplying the auditor with any information that could affect the efficiency of the audit once the auditor is on-site.
History —Aug. 29, 2011, No. 194, § 6.060, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 8, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9087/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9087 - Provider audit coordinators
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9087 - Provider audit coordinators
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(a) Providers shall designate an individual to coordinate all claim audit activities. An audit coordinator shall have the same qualifications as required for an auditor pursuant to § 9085 of this title. The duties of an audit coordinator include, among others, the following:
(1) Scheduling an audit to be carried out during business hours;
(2) advising other provider personnel and departments of a pending audit;
(3) ensuring that the condition of admission statement is part of the clinical record;
(4) verifying that the auditor is an authorized representative of the health insurance organization or issuer;
(5) gathering the necessary documents for the audit;
(6) coordinating auditor requests for information, space in which to conduct an audit, and access to records and provider personnel;
(7) orienting auditors with respect to the provider’s audit procedures, record documentation conventions, and billing practices;
(8) acting as a liaison between the auditor and other personnel of the provider;
(9) conducting an exit interview with the auditor to answer questions and review audit findings;
(10) reviewing the auditor’s final written report and following up on any charges still in dispute;
(11) arranging for payment as applicable, and
(12) arranging for any required adjustment to bills or refunds.
History —Aug. 29, 2011, No. 194, § 6.070, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 9, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9088/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9088 - Conditions and scheduling of audits
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9088 - Conditions and scheduling of audits
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(a) In order to have a fair, efficient, and effective audit process, providers and health insurance organization or issuer’ [sic] auditors shall adhere to the following requirements:
(1) Whatever the original intended purpose of the claim audit, all parties shall agree to recognize, record or present any identified unsupported, unbilled or underbilled charges discovered by the audit parties;
(2) the scheduling of an audit shall not preclude late billing;
(3) the parties involved in the audit shall mutually agree to set a time frame for the resolution of any discrepancies, questions or errors that surface in the audit;
(4) an exit conference and a written report shall be part of each audit. If the provider waives the exit conference, the auditor shall note that action in the written report. The specific content of the final report shall be restricted to those parties involved in the audit;
(5) the provider shall be afforded forty (40) calendar days to contest all findings, after which the audit shall be considered final;
(6) once both parties agree to the audit findings, audit results are final;
(7) all personnel involved shall maintain a professional, courteous manner and resolve all misunderstandings amicably, and
(8) if the auditor notes ongoing problems either with the billing or documentation process and it cannot be corrected as part of the exit process, the management of the provider and health insurance organization or issuer shall be contacted to apprise them of the situation. The provider and health insurance organization or issuer shall take appropriate steps to resolve the identified problem. Parties to an audit shall eliminate ongoing problems or questions whenever possible as part of the audit process.
History —Aug. 29, 2011, No. 194, § 6.080, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 10, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9089/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9089 - Confidentiality and authorizations
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9089 - Confidentiality and authorizations
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(a) All parties to a claim audit shall recognize and comply with all federal and Commonwealth laws and any contractual agreements regarding the protection of information within clinical records and the confidentiality and security of patient information.
(b) The release of medical records requires authorization from the patient. An authorization to release such records shall be included in the statement of diagnosis procured by the provider upon admission of the patient. If no such statement is obtained, a separate authorization for a claim audit is required. The authorization need not be specific as to the health insurance organization or issuer or auditor conducting the audit.
(c) The authorization shall be obtained by the person conducting the claim audit or the provider, and shall include the standard information provided through policy letter by the Commissioner and in accordance with subsections (a) and (b) of this section.
(d) A patient’s assignment of benefits shall include a presumption of authorization to review records.
(e) The audit coordinator shall confirm to the audit representative that a statement of diagnosis is available for the particular audit that needs scheduling.
(f) The provider shall inform the patient or requestor, on a timely basis, if there are any federal or Commonwealth laws prohibiting or restricting review of the medical record and if there are institutional confidentiality policies and procedures that affect the review of such documents. These institutional confidentiality policies shall not be specifically oriented in order to delay an external audit.
History —Aug. 29, 2011, No. 194, § 6.090, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 11, eff. 30 days after July 10, 2103.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9090/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9090 - Documentation
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9090 - Documentation
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(a) Verification of charges shall include the investigation of whether or not:
(1) Charges are reported on the bill accurately;
(2) services are documented in medical or other records as having been rendered to the patient, and
(3) Services were delivered in compliance with the physician’s plan of treatment. In appropriate situations, professional staff may provide supplies or follow procedures that are in accordance with established institutional policies, procedures, or professional licensure standards. Many procedures include items that are not specifically documented in a clinical record but are referenced in medical or clinical policies. Such policies shall be reviewed, approved, and documented as required by the Joint Commission on Accreditation of Healthcare Organizations or other accreditation agencies. Policies shall be available for review by the auditor.
(b) The clinical record documents clinical data on diagnoses, treatments and results. It is not designed to be a billing document. A patient’s clinical record generally documents pertinent information related to care and may not back up each individual charge on the patient bill. Other signed documentation for services provided to the patient may exist within the provider’s ancillary departments in the form of department treatment logs, daily records, individual service or order tickets, and other documents.
(c) Auditors may review a number of other documents to determine valid charges. Auditors must recognize that these sources of information are accepted as reasonable evidence that the services ordered by the physician were actually provided to the patient. Providers must ensure that proper policies and procedures exist to specify what documentation and authorizations must be in the clinical record and in ancillary records and logs. These procedures must also document that services have been properly ordered for and delivered to patients. When sources other than the clinical record are furnishing documentation, the provider shall notify the auditor and make those sources available to him/her.
History —Aug. 29, 2011, No. 194, § 6.100, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 12 eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-104/9091/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091)›§ 9091 - Fees and payments
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 104 - Health Insurance Organizations or Issuers Claim Audits (§§ 9081 — 9091) › § 9091 - Fees and payments
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(a) A health insurance organization or issuer shall make prompt payment of a bill in accordance with the provisions of §§ 301–335 of this title and shall not delay payment for an audit process. Payment on a submitted bill from a third-party shall be based on amounts billed and covered by the patient’s health plan.
(b) Audit fees shall be paid upon commencement of the claim audit.
(c) A payment identified in the audit results that is owed to either party by the other, shall be settled by the audit parties within a reasonable period of time not to exceed thirty (30) days after completion of the audit unless the parties agree otherwise.
History —Aug. 29, 2011, No. 194, § 6.110, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9121/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9121 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9121 - Title
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This chapter shall be known and may be cited as the chapter on Small- and Medium-sized Businesses (PYMES, Spanish acronym) Employer Health Insurance Availability.
History —Aug. 29, 2011, No. 194, § 8.010, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9122/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9122 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9122 - Purpose
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The purpose of this chapter is to enhance the availability of health insurance coverage to PYMES employers regardless of their health status or claims experience, to prevent abusive rating practices, to prevent segmentation of the health insurance market based upon health risk, to require disclosure of rating practices to purchasers, to establish rules regarding renewability of coverage, to limit the use of preexisting condition exclusions, to provide for development of health plans that meet the requirements of the essential health benefit package to be offered to all PYMES employers, and to improve the overall fairness and efficiency of the small group health insurance market. This chapter shall be governed by the regulatory provisions of the Patient Protection and Affordable Care Act, as issued by federal regulatory agencies.
History —Aug. 29, 2011, No. 194, § 8.020, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 13, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9123/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9123 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9123 - Definitions
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For purposes of this chapter:
(a) Affiliate or affiliate company.— Means any entity or person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under the same control that a specific entity or person.
(b) Geographic service area.— Means a geographic area, as constituted and delimited by the Commissioner through policy letter to such purposes, within which the issuer is authorized to provide coverage under the provisions of this chapter. The issuer shall faithfully comply with the provisions of §§ 3041 et seq. of Title 24, particularly § 3044(b) of Title 24, related to all geographic service areas in which it is authorized to provide coverage.
(c) Issuer or PYMES employer issuer.— Means any entity authorized by the Commissioner to offer health plans to eligible employees of one (1) or more PYMES employers pursuant to this chapter. For purposes of this chapter “issuer” includes an insurance company, a prepaid hospital or medical care plan, a fraternal benefit society, a health services organization, and any other entity offering and providing a health plan or health benefits subject to insurance regulation in Puerto Rico.
(d) Actuarial certification.— Means a signed statement from a member of the American Academy of Actuaries or other individual acceptable to the Commissioner that a PYMES employer issuer is in compliance with the provisions of this chapter. Such certification shall be based upon the person’s examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the issuer in establishing premium rates for applicable insurance coverage.
(e) Creditable coverage.— Means, with respect to an individual, the health benefits or coverage provided under any of the following:
(1) A health plan, whether group or individual.
(2) Part A or Part B of Title XVIII of the Social Security Act (Medicare).
(3) Title XIX of the Social Security Act (Medicare), other than coverage consisting solely of benefits under Section 1928 (the program for distribution of pediatric vaccines).
(4) Chapter 55 of Title 10, United States Code; (medical and dental care for members and certain former members of the uniformed services, and for their dependents. For purposes of Title 10, U.S.C. Chapter 55, “uniformed services” means the armed forces and the Commissioned Corps of the National Oceanic and Atmospheric Administration and of the Public Health Service).
(5) A state health benefits risk pool.
(6) A health plan offered under Chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program (FEHBP)).
(7) A public health plan, which for purposes of this chapter, means a plan established or maintained by a state, the United States government or a foreign country or any political subdivision of a state, the United States government or a foreign country that provides health insurance coverage to individuals enrolled in the plan.
(8) A health plan under Section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e)).
(9) Title XXI of the Social Security Act (State Children’s Health Insurance Program).
A period of creditable coverage shall not be counted, with respect to the enrollment of an individual who seeks coverage under a group plan, if, after such period and before the enrollment date, the individual experiences a significant break in coverage. Significant break in coverage shall be understood as a period of sixty-three (63) consecutive days during which the individual does not have any creditable coverage. A waiting period or an affiliation period shall be taken into account in determining the sixty-three (63)-day period.
(f) Eligible employee.— Means an employee who works for a PYMES employer on a full-time basis-a normal work week of thirty (30) or more hours-or on a part-time basis-a normal week of at least seventeen point five (17.5) hours-in a bona fide employer-employee relationship which has not been established for the purpose of acquiring a health plan. In this computation, those employees who are not currently working as a result of any leave or right recognized by law, such as the benefits provided by the State Insurance Fund Corporation or the Family and Medical Leave Act of 1993, shall be included. The term “eligible employee” shall not include temporary employees or independent contractors.
(g) Preexisting condition exclusion.— Means a limitation or exclusion of benefits relating to a condition based on the fact that the condition, injury, or disease was present before the enrollment date of the health plan. Genetic information shall not be treated as a condition for which a preexisting condition exclusion may be imposed in the absence of a diagnosis of the condition related to the information.
(h) Health status-related factor.— Means any of the following factors:
(1) Health status;
(2) medical condition, including both physical and mental illnesses;
(3) claims experience;
(4) receipt of healthcare services;
(5) medical history;
(6) genetic information;
(7) evidence of insurability, including conditions arising out of acts of domestic violence and participation in activities such as motorcycling, all-terrain vehicle riding, horseback riding, skiing and other similar high-risk activities, or
(8) disability.
(i) Enrollment date.— Means the first day of coverage, or if there is a waiting period, the first day of the waiting period, whichever comes first.
(j) Genetic information.— Means information about genes, gene products and inherited characteristics that may derive from the individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes.
(k) Small- and Medium-sized Businesses (PYMES) Employer.— Means a for-profit or non-profit person, firm, corporation, partnership, or association that employed at least two (2), but no more than fifty (50) eligible employees on at least fifty percent (50%) of its business days during the preceding calendar year. In determining the number of eligible employees, companies that are affiliated companies or that are eligible to file a combined tax return for purposes of taxation in Puerto Rico shall be considered one employer. After the issuance of a health plan and for the purpose of determining continued eligibility, the size of a PYMES employer shall be determined annually. As of January 1, 2016, or subject to the provisions of the regulations related to the Patient Protection and Affordable Care Act, PYMES employers shall include businesses with up to 100 employees.
(l) Waiting period.— Means the period of time that must pass before coverage for a covered person or enrollee who is otherwise eligible to enroll under the terms of a health plan can become effective. In no case the waiting period shall exceed ninety (90) days.
(m) Enrollment period.— Means a period of time established for an eligible employee to enroll in a PYMES employer-sponsored health plan.
(n) Covered person or enrollee.— Means the holder of a policy or certificate, or other individual participating in a PYMES employer-sponsored health plan.
(o) Preferred network plan.— Means a health plan under which benefits shall be provided, in whole or in part, through providers under contract with the issuer.
(p) Health plan.— Means an insurance policy, contract, or certificate provided in consideration of or in exchange for the payment of a premium, or on a pre-paid basis, through which an issuer commits to provide coverage or pay for the costs of or specified healthcare services, hospital, major medical, dental coverage, mental health services or services incidental to the rendering thereof.
(1) “Health plan” shall not include:
(A) Coverage only for accident, or disability income insurance, or any combination thereof;
(B) coverage issued as a supplement to liability insurance;
(C) liability insurance, including general liability insurance and automobile liability insurance;
(D) workers’ compensation insurance;
(E) automobile medical payment insurance;
(F) credit-only insurance;
(G) coverage for on-site medical clinics, or
(H) other similar insurance coverage under which benefits for health services are secondary or incidental to other insurance benefits.
(2) “Health plan” shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
(A) Limited scope dental or vision benefits;
(B) benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof, or
(C) other similar, limited benefits.
For purposes of this subsection, benefits shall not be considered an integral part of the plan, if they fail to meet the following requirements:
(i) Enrollees may choose not to receive coverage for such benefits, that is, the benefits provided are optional, and
(ii) enrollees are required to pay a premium or additional contribution for such optional benefit coverage.
(3) “Health plan” shall not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance:
(A) Coverage only for a specified disease or illness;
(B) hospital indemnity or other fixed indemnity insurance;
(C) medicare supplemental health insurance;
(D) coverage supplemental to the coverage provided (known as TRICARE supplemental programs), or
(E) similar supplemental coverage provided to coverage under a group health plan.
(q) Basic health plan.— Means a health plan that meets the requirements of the Essential Health Benefits Package developed according to § 9005 of this title and as defined in the regulations adopted under the provisions of the Patient Protection and Affordable Care Act.
(r) Bronze Level Health Plan, Silver Level Health Plan, Gold Level Health Plan, and Platinum Level Health Plan.— Means a basic health plan with coverage in the Bronze Level, Silver Level, Gold Level, and Platinum Level, respectively, as defined in § 9005 of this title.
(s) Group health plan.— Means a policy, contract, or certificate offered by a health insurance organization or issuer to a PYMES employer or group of PYMES employers whereby healthcare services are provided to eligible employees and their dependents.
(t) Premium.— Means all moneys paid to an issuer as a condition of receiving the benefits of a health plan for the eligible employees of PYMES employers.
(u) Producer.— Means a person who, in accordance with the Insurance Code of Puerto Rico, holds a license duly issued by the Commissioner to transact insurance in Puerto Rico.
(v) Late enrollee.— Means an eligible employee or dependent that enrolls in a PYMES employer-sponsored health plan after the initial enrollment period; Provided, That such term shall never be less than thirty (30) days.
No eligible employee or dependent shall be considered a late enrollee:
(1) If the eligible employee or dependent meets each one of the following criteria:
(A) Was covered under a creditable coverage at the time of initial enrollment;
(B) lost creditable coverage as a result of cessation of employer contribution, termination of employment or loss of eligibility, reduction in the number of work hours, involuntary termination of a creditable coverage, death of a spouse, legal separation or divorce, and
(C) requests enrollment within thirty (30) days after termination of creditable coverage or the change in conditions that gave rise to the termination of coverage.
(2) If, where provided for in the health plan, or as otherwise provided by law, the eligible employee or dependent enrolls during a specified enrollment period.
(3) If the eligible employee is employed by an employer that offers multiple health plans, and he/she elects a different health plan during the enrollment period.
(4) If a court has ordered coverage be provided for a spouse or minor or dependent child under an employe’s health plan and a request for enrollment is made within thirty (30) days after the change in status.
(5) If the individual changes status from not being an eligible employee to becoming an eligible employee and requests enrollment within thirty (30) days after the change in status.
(6) If the eligible employee or dependent had coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation provision and the coverage under that provision has been exhausted.
(7) The eligible employee meets the requirements for special enrollment pursuant to this chapter.
(w) Community adjusted rate.— Means a method used to develop rates, which spreads financial risk across the entire small group population of the issuer in accordance with the requirements in Section 5 of this Chapter [sic].
History —Aug. 29, 2011, No. 194, § 8.030, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 14, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9124/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9124 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9124 - Applicability and scope
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(a) This chapter shall apply to an issuer that offers health plans to the employees of PYMES employers in Puerto Rico, provided that the PYMES employer pays all or part of the premium or benefits, or the eligible employee is reimbursed for any portion of the premium, whether through wage adjustments or otherwise, as agreed upon by the parties.
(b) For the purposes of this chapter, issuers that are affiliated companies or that are eligible to file a consolidated tax return shall be treated as one issuer and any restrictions or limitations imposed by this chapter shall apply as if all health plans issued for delivery to PYMES employers in Puerto Rico by such affiliated issuers were issued by one issuer.
(c) Those issuers that which to contract with the Puerto Rico Health Insurance Administration (ASES, Spanish acronym) to offer, market, or administer the Mi Salud Plan for PYMES, shall meet the requirements and legal and regulatory provisions established by ASES, the Insurance Code of Puerto Rico, and this chapter. Provided, That in the case of the Mi Salud Plan for PYMES, the rules established by ASES regarding the following shall apply to issuers:
(1) Geographic service area;
(2) the criteria to determine the eligibility of the PYMES employer, as well as the employees thereof and their dependents;
(3) the development and definition of the health plan or plans and the coverage thereof;
(4) issues related to premium rate models, methods, and practices, and premiums to be paid, and
(5) the eligibility criteria to be met by participating issuers.
It is hereby provided further that those issuers that are not offering, marketing or administering a health plan for any PYMES employer in Puerto Rico and wish to contract with ASES for the Mi Salud Plan for PYMES, shall request and obtain the approval or dispensation of the Commissioner to participate in such Mi Salud Plan for PYMES.
History —Aug. 29, 2011, No. 194, § 8.040, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 15, eff. 30 days after July 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9125/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9125 - Restrictions relating to premium rates
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9125 - Restrictions relating to premium rates
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(a) Premium rates for health plans shall be subject to the following provisions:
(1) The PYMES employer issuer shall develop its rates based on an adjusted community rate and may only vary the adjusted community rate with regards to geographic area, family composition, age, and tobacco use.
(2) Any adjustment shall be made according to the rules and conditions prescribed by the Commissioner through policy letter.
(3) Issuers shall be permitted to develop separate rates for individuals age sixty-five (65) or older notwithstanding that Medicare is the primary payer. Both rates shall be subject to the requirements of this section.
(4) As of the approval of this act, rate adjustments based on age shall be those determined by the Commissioner of Insurance.
(b) The premium charged for a health plan may not be adjusted more frequently than annually, except that the rates may be changed to reflect:
(1) Changes to the enrollment of the PYMES employer;
(2) changes to the family composition of the eligible employee, or
(3) changes to the health plan requested by the PYMES employer.
(c) Rating factors shall produce premiums for identical groups which differ only by the amounts attributable to plan design and do not reflect differences due to the nature of the groups assumed to select particular health plans.
(d) The Commissioner may establish, through policy letter, the rating practices to be used by PYMES employer issuers that are consistent with the purposes of this chapter.
(e) Each issuer shall maintain at its principal place of business, for review by the Commissioner, a complete and detailed description of its rating practices and renewal underwriting practices. In addition, such issuer shall maintain information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles. Also, issuers shall meet the following requirements:
(1) Each PYMES employer issuer shall file with the Commissioner annually, not later than March 15, an actuarial certification certifying that it is in compliance with this chapter and that the rating methods of the PYMES employer issuer are actuarially sound. The certification shall be in a form and manner, and shall contain such information, as specified by the commissioner. A copy of the certification shall be retained by the PYMES employer issuer at its principal place of business.
(2) A PYMES employer issuer shall make the information and documentation described in this subsection available to the Commissioner for inspection upon request. Except in cases of violations of this chapter, the information shall be considered proprietary and trade secret information and shall not be subject to disclosure by the Commissioner to persons outside of the Office, except as agreed to by the issuer or as ordered by a court of competent jurisdiction.
(f) The requirements of this section shall apply to all health plans issued or renewed on or after the effective date of this chapter.
History —Aug. 29, 2011, No. 194, § 8.050, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 16, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9126/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9126 - Renewability of health plan
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9126 - Renewability of health plan
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(a) An issuer providing health plans to PYMES employers shall renew the same to all eligible employees and their dependents, except in any of the following cases:
(1) Failure to pay premiums, considering the grace period.
(2) When the covered person or enrollee has performed an act that constitutes fraud. In such case the issuer may choose not to renew the health plan of such covered person or enrollee for one (1) year as of the of the [sic] coverage’s termination date.
(3) When the covered person or enrollee has or made an intentional misrepresentation of material fact under the terms of coverage. In such case the issuer may choose not to renew the health plan of such covered person or enrollee for one (1) year as of the of the [sic] coverage’s termination date.
(4) Noncompliance with the issuer’s minimum participation requirements, pursuant to the provisions of this chapter.
(5) Noncompliance with the issuer’s employer contribution requirements.
(6) When the issuer elects to discontinue offering all of its health plans to PYMES employers in Puerto Rico. In these cases, the issuer shall provide a written notice to the Commissioner, the PYMES employer, and the covered persons or enrollees, of its decision not to renew coverage at least one hundred and eighty (180) days prior to the nonrenewal of the health plans. The issuer that elects to discontinue offering health plans, as provided herein, shall be impaired from underwriting new business in the PYMES employer market in Puerto Rico for a term of five (5) years, beginning on the date in which the issuer ceased to offer such health plans.
(7) When the commissioner finds that the continuation of the coverage would not be in the best interests of the policyholders or would impair the issuer’s ability to meet its contractual obligations.
(8) In the case of health plans that are made available in the small group market through a preferred network plan, there is no longer an employee of the PYMES employer living, working, or residing within the issuer’s established geographic service area.
(b) In the case of a PYMES employer issuer doing business in one established geographic service area of Puerto Rico, the rules set forth in this section shall apply only to the issuer’s operations in that service area.
(c) In addition to comply with the provisions of this section, the issuer shall comply, at all times, with the applicable federal regulations, as codified under 45 C.F.R. Section 146.152 (Guaranteed renewability of coverage for employers in the group market).
History —Aug. 29, 2011, No. 194, § 8.060, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9127/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9127 - Availability of health plan
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9127 - Availability of health plan
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(a) As a condition for transacting business in Puerto Rico, employers and, except for the provisions of this chapter, those issuers offering insurance to PYMES employers shall offer all the health plans that they actively market to PYMES employers, including at least two (2) basic health plans in at least one metal level each. Issuers shall also meet the following availability requirements:
(1) A PYMES employer issuer shall issue a health plan to any eligible employer that applies for such plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health plan not inconsistent with this chapter.
(2) Unless otherwise provided by the Commissioner, the PYMES employer issuer shall not enter into one or more ceding agreements with respect to health plans delivered or issued for delivery for PYMES employers in Puerto Rico, if such arrangements would result in less than fifty percent (50%) of the insurance obligation or risk for such health plan being retained by the ceding issuer.
(b) Issuers shall file with the Commissioner the health plan forms and rates they intend to market. The issuer may begin using such forms sixty (60) days after they are filed unless the Commissioner disapproves their use. Provided, That:
(1) The Commissioner, at any time, may extend such term for not more than sixty (60) additional days.
(2) The Commissioner at any time may, after providing notice and an opportunity for a hearing, disapprove the use of a basic or standard health plan on the grounds that the plan does not meet the requirements of this chapter or the regulations thereunder.
(c) Health plans covering PYMES employers shall comply with the following provisions:
(1) A health plan shall not deny, exclude or limit benefits due to a preexisting condition in the case of an individual under the age of 19.
(2) In the case of an individual older than nineteen (19) years [of age], the issuer may deny, exclude or limit the benefits due to a preexisting condition for a maximum period of six (6) months as of the effective date of the health plan.
(3) The health plan shall not define a “preexisting condition” more broadly than a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately before the individual’s enrollment date.
(4) As of 2014, health plans shall not deny, exclude or limit benefits for a person due to a preexisting condition regardless of the person’s age.
(5) Furthermore, PYMES employer issuers shall comply with the following provisions regarding preexisting conditions:
(A) A PYMES employer issuer shall reduce the period of any preexisting condition denial, limitation, or exclusion provided that the person has had creditable coverage and that such creditable coverage ended on a date not more than ninety (90) days prior to the enrollment date of new health plan. The reduction provided in this paragraph shall be for the entirety of the creditable coverage period.
(B) An issuer that does not use preexisting condition limitations in any of its health plans may impose an affiliation period that shall not exceed sixty (60) days for new enrollees and ninety (90) days for late enrollees. Such affiliation periods shall apply uniformly without regard to any health status-related factor.
(6) PYMES employer issuers shall not impose exclusion for preexisting condition relating to pregnancy.
(7) Issuers shall permit late enrollees to enroll for coverage under the terms of the health plan during a special enrollment period if:
(A) The late enrollee was covered under a health plan at the time PYMES employer sponsored health plan was previously offered, including a health plan under the Consolidated Omnibus Budget Reconciliation Plan Act (COBRA).
(B) The other health plan of the late enrollee has been terminated as a result of loss of eligibility for coverage, including a legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment or employer contributions towards that other coverage have been terminated.
(C) The late enrollee requests enrollment in a PYMES employer sponsored health plan not later than thirty (30) days after the date termination of coverage under another plan.
If an employee requests enrollment pursuant to this clause, the PYMES employer-sponsored health plan shall be effective not later than the first calendar month after the date on which the request for enrollment was received.
(8) Issuers that provide PYMES employer-sponsored health plans shall establish a dependent special enrollment period during which the dependent and the eligible employee, if not otherwise enrolled, may be enrolled under the health plan and, in the case of the birth or adoption of a child, award of custody or guardianship, or marriage. The special enrollment period for persons who comply with the provisions of this paragraph (8) of this clause shall be a period of thirty (30) days and shall begin on the later date of:
(A) The date on which the health plan is made available for such dependent, or
(B) the date of the marriage, birth or adoption, or award of custody or guardianship.
If an eligible employee seeks to enroll a dependent during the first thirty (30) days of the dependent special enrollment period, the effective date of the health plan of the dependent shall be:
(i) in the case of marriage, the first day of the month beginning after the date on which the request for enrollment was received,
(ii) in the case of a dependent’s birth, as of the date of birth; and
(iii) in the case of a dependent’s adoption award of custody or guardianship, the date of the adoption or award.
(9) PYMES employer issuers shall not require a minimum participation level greater than:
(A) One hundred percent (100%) of eligible employees working for employers of three (3) or less employees, and
(B) seventy-five percent (75%) of eligible employees working for employers with more than four (4) employees.
In applying minimum participation requirements with respect to a PYMES employer, an issuer shall not consider employees or dependents who have creditable coverage in determining whether the applicable percentage of participation is met. Individuals covered under a health plan pursuant to continuation provisions of COBRA shall not be considered.
Issuers shall not increase any requirement for minimum employee participation or modify any requirement for minimum employer contribution applicable to a PYMES employer at any time after such employer has been accepted for the health plan.
(10)
(A) An issuer that offers a health plan shall offer the same plan to all eligible employees of such PYMES employer and their dependents. Issuers shall not offer coverage to only certain individuals or dependents in a group.
(B) PYMES employer issuers shall not place any restriction in regard to any health status-related factor on an eligible employee or dependent with respect to enrollment or plan participation.
(C) Except as permitted under this chapter, issuers shall not modify a health plan with respect to a PYMES employer or any eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage or benefits of the health plan related to specific diseases, medical conditions, or services.
(d) PYMES employer issuers shall not be required to offer health plans or accept applications in the case of the following:
(1) To a PYMES employer, if such employer is not located in the issuer’s established geographic service area.
(2) To an employee, if the employee does not live, work or reside within the issuer’s established geographic service area.
Issuers shall apply the provisions of this section uniformly to all PYMES employers, regardless of their claim experience or any health status-related factor of their eligible employees and their dependants.
(e) A PYMES employer issuer shall not be required or allowed to provide coverage to PYMES employers if, for any period of time, the Commissioner determines that the such issuer does not meet the necessary criteria or lacks the financial reserves necessary to underwrite health plans.
(1) In making such determination, the Commissioner shall take into account the following factors:
(A) The issuer’s financial condition.
(B) The issuer’s history of rating and underwriting PYMES employer groups.
(C) The issuer’s commitment to market its products fairly to all PYMES employers in Puerto Rico or in its geographic service area, as applicable.
(D) The issuer’s experience with managing risks concerning PYMES employer groups.
(E) The issuer’s financial condition will no longer support the assumption of risk from issuing health plans to PYMES employers.
(F) The issuer has failed to market its products fairly to all PYMES employers in Puerto Rico or in its geographic service area, as applicable.
(G) The issuer has failed to provide coverage to eligible PYMES employers as required in this section.
(2) In these cases, the issuer shall not offer health plans in the PYMES employer group market before the latest of the following dates:
(A) One hundred eighty (180) days after the date in which the Commissioner made the determination, or
(B) until the issuer has demonstrated to the Commissioner that it has sufficient financial reserves to underwrite health plans to PYMES employers and the Commissioner has authorized it once again to offer health plans to PYMES employers.
(f) A PYMES employer issuer shall not be required to provide coverage to PYMES employers if the issuer elects not to offer new health plans to PYMES employers in Puerto Rico. Provided, further, That:
(1) The issuer that elects not to offer new health plans to PYMES employers may be allowed to maintain its existing policies in Puerto Rico, as determined by the Commissioner.
(2) The issuer that elects not to offer new health plans to PYMES employers shall provide notice of its election to the Commissioner, who shall ban the issuer from writing new health plans in the PYMES employer market in Puerto Rico for a period of five (5) years beginning on the date the issuer ceased offering new health plans in Puerto Rico.
History —Aug. 29, 2011, No. 194, § 8.070, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 17, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9128/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9128 - Certification of creditable coverage
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9128 - Certification of creditable coverage
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(a) PYMES employer issuers shall provide written certification of creditable coverage to individuals in accordance with subsection (b) of this section.
(b) The certification of creditable coverage shall be provided:
(1) At the time an individual ceases to be covered under the health plan or otherwise becomes covered under a COBRA continuation provision.
(2) In the case of an individual who becomes covered under a COBRA continuation provision at the time the individual ceases to be covered under that provision.
(c) The certificate of creditable coverage required to be provided pursuant to section shall contain:
(1) The period of creditable coverage of the individual under the other health plan, and
(2) the waiting period, if any, and, if applicable, affiliation period imposed with respect to the individual for any coverage under another health plan.
History —Aug. 29, 2011, No. 194, § 8.080, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9129/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9129 - Repealed. Act July 10, 2013, No. 55, § 18, eff. 30 days after July 10, 2013
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9129 - Repealed. Act July 10, 2013, No. 55, § 18, eff. 30 days after July 10, 2013
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History Aug. 29, 2011, No. 194, —Aug. 29, 2011, No. 194, § 8.090, eff. 180 days after Aug. 29, 2011; Act July 10, 2013, No. 55, § 18, eff. 30 day after July 10, 2013, effective July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9130/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9130 - Transitory provisions for issuers offering health plans to PYMES employers
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9130 - Transitory provisions for issuers offering health plans to PYMES employers
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(a) Issuers interested in offering and marketing, or who wish to continue offering and marketing the health plans authorized under this chapter, or any other designed for PYMES employers in Puerto Rico, shall comply with the following:
(1) As a transition measure, and while the provisions of this chapter are implemented entirely, it is hereby provided that any issuer that is offering, marketing, or administering any health plan for one or more PYMES employers at the time of the approval of this act may continue to do so.
(2) The preceding clause notwithstanding, such issuer shall provide, within a term of thirty (30) days, a notice to the Commissioner stating:
(A) The date on which it began offering, marketing or administering health plans for PYMES employers.
(B) the number of health plan models available for PYMES employers, classified as marketed, exclusive or administered, and if the latter has any stop loss coverage;
(C) the number of PYMES employers and enrollees that are enrolled by type of health plan, following the aforementioned classification;
(D) rate or rates for these health plans and the basis to determine the same, as well as those used and underwritten;
(E) a table itemizing the covered benefits, exclusions, and limitations, applicable deductible, copayments and coinsurance, eligible employees and dependents, and premiums applicable for individuals, family groups, the employee and one dependent (partner), for optional dependents or collaterals, as such terms and practices are commonly accepted and defined in the health insurance market, and
(F) any other information that may be necessary to achieve the purposes of this chapter.
(b) It is hereby further provided, that every issuer that, at the time of the approval of this chapter has underwritten any health plan for a PYMES employer, may continue to renovate the same, as provided in the applicable federal regulations, codified under 45 C.F.R. Section 146.152 (Guaranteed renewability of coverage for employers in the group market) and 147.140 (Preservation of right to maintain existing coverage), promulgated pursuant to Public Law 111-148, known as the Patient Protection and Affordable Care Act, and Public Law 111-152, known as the Health Care and Education Reconciliation Act.
History —Aug. 29, 2011, No. 194, § 8.100, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 19, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9131/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9131 - Repealed. Act July 10, 2013, No. 55, § 18, eff. 30 days after July 10, 2013
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9131 - Repealed. Act July 10, 2013, No. 55, § 18, eff. 30 days after July 10, 2013
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History Aug. 29, 2011, No. 194, —Aug. 29, 2011, No. 194, § 8.110, eff. 180 days after Aug. 29, 2011; Act Aug. 9, 2013, No. 55, § 20, effective July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9132/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9132 - Basic health plan
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9132 - Basic health plan
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(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.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9133/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9133 - Periodic market evaluation
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9133 - Periodic market evaluation
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The Commissioner shall conduct a study at least every three (3) years on the effectiveness of the provisions of this chapter. The report shall analyze the effectiveness of the provisions of this chapter in promoting rate stability, product availability, and coverage affordability of health plans for PYMES employers. The report may contain recommendations for improvements to the overall effectiveness, efficiency, and fairness of the small group health insurance market. The report shall address whether issuers and producers are fairly and actively marketing or issuing health plans to PYMES employers in accordance with the purposes of the chapter. The report may contain recommendations regarding market conduct or other regulatory standards or actions.
History —Aug. 29, 2011, No. 194, § 8.130, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 22, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9134/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9134 - Waiver of certain Commonwealth laws
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9134 - Waiver of certain Commonwealth laws
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No Commonwealth law or regulation approved after the effective date of this chapter requiring the coverage of a healthcare service or benefit, or requiring the reimbursement, utilization or inclusion of a specific category of healthcare provider or person, shall apply to the health plans delivered by PYMES employer issuers in Puerto Rico, unless as otherwise provided by the law or regulation in question. However, any issuer may elect to comply with the provisions of the law or approved regulation, if doing so inures to the benefit of PYMES employers, as well as their employees and the dependents thereof.
History —Aug. 29, 2011, No. 194, § 8.140, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9135/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9135 - Administrative procedures
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9135 - Administrative procedures
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The Commissioner shall issue policy letters or regulations as necessary for the implementation of the provisions of this chapter following the procedure established therefor in §§ 201-232 of this title.
History —Aug. 29, 2011, No. 194, § 8.150, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 23, eff. 30 days after July 10, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9136/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9136 - Standards to assure fair marketing
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9136 - Standards to assure fair marketing
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(a) Each issuer shall actively market all health plans sold by the issuer to all PYMES employers in Puerto Rico.
(b) No PYMES employer issuer or producer shall, directly or indirectly, engage in the following activities:
(1) Encouraging or directing PYMES employers to refrain from filing an application for coverage with the PYMES employer issuer because of any health status-related factor, industry, occupation or geographic location of the PYMES employer. This provision shall not apply with respect to information provided by a PYMES employer issuer or producer regarding the established geographic service area or a preferred network provision.
(c) No issuer shall, directly or indirectly, enter into any contract, agreement or arrangement with a producer that provides for or results in the compensation paid to a producer for the sale of a health plan to be varied because of any initial or renewal health status-related factor of eligible employees or dependents, or industry, occupation or geographic location of the PYMES employer. This provision shall not apply with respect to a compensation arrangement that provides compensation to a producer on the basis of percentage of premium, provided that the percentage shall not vary because of any health status-related factor of eligible employees or dependents, or industry, occupation or geographic location of the PYMES employer.
(d) No issuer may terminate, fail to renew or limit its contract or agreement of representation with a producer for any reason related to any initial or renewal health status-related factor of eligible employees or dependents, or industry, occupation or geographic location of the PYMES employer placed by the producer.
(e) An issuer or producer may not induce or otherwise encourage a PYMES employer to separate or otherwise exclude an eligible employee or dependent from the benefits of a health plan.
(f) Denial by an issuer of an application for health plan from a PYMES employer, for any of the reasons permitted in accordance with the provisions of this chapter, shall be in writing and shall state the reason or reasons for the denial.
(g) Any violation of this section shall be an unfair trade practice under §§ 2701–2740 of this title and shall be subject to the sanctions provided therein. If an issuer enters into a contract, agreement or other arrangement with a third-party administrator to provide administrative, marketing or other services related to the offering of health plans to PYMES employer in Puerto Rico, the third-party administrator shall be subject to this section as if it were an issuer.
History —Aug. 29, 2011, No. 194, § 8.160, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-106/9137/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137)›§ 9137 - Required disclosure
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9137 - Required disclosure
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(a) In connection with the offering for sale of any health plan to a PYMES employer, the issuer shall make a reasonable disclosure, as part of its solicitation and sales materials, of all of the following:
(1) The provisions of the health plan that, in accordance with this chapter, grant the issuer the right to change rates and the factors therefor, other than claim experience.
(2) The provisions related to the possibility of renewal of policies and contracts.
(3) The provisions related to preexisting conditions.
(4) A listing and descriptive information, including benefits and premiums, on all health plans available for PYMES employers.
History —Aug. 29, 2011, No. 194, § 8.170, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9161/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9161 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9161 - Title
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This chapter shall be known and cited as the Chapter on Individual Health Plan and Guaranteed Availability.
History —Aug. 29, 2011, No. 194, added as § 10.010 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9162/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9162 - Public policy
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9162 - Public policy
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The purpose of this chapter is to enhance the availability of health insurance coverage to persons who are not insured under an employer or labor union group health plan, regardless of their health status or claim experience; to prevent abusive rating practices; to require disclosure of rating practices in the individual market; to establish rules regarding renewability of coverage; eliminate the use of preexisting condition exclusions; provide for the development of individual basic health plans in their various metal levels of coverage; promote and guarantee equal access to health plans; improve overall fairness and efficiency in the individual health plan market; and regulate the guaranteed availability of policies in the individual market through the implementation of an enrollment period.
History —Aug. 29, 2011, No. 194, added as § 10.020 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9163/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9163 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9163 - Definitions
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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.
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9164 - Applicability and scope
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9164 - Applicability and scope
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(a) The provisions of this chapter concerning individual health plans and the issuers that offer them shall apply to:
(1) Individual health plan offered to and that covers enrollees and their dependents who are residents of Puerto Rico or dependents who study and reside outside of Puerto Rico at the time of issue, regardless of the number of health plans that the enrollee has. In the case of guaranteed availability required by this chapter, the same shall apply to such individual health plans, if the enrollee is not covered and is not eligible for an employee-sponsored group health plan;
(2) any certificate issued to an enrollee that evidences coverage under a policy or contract issued to a trust or association or other similar grouping of individuals, which are not contingent on employer relation, regardless of the situs of delivery of the policy or contract, if the enrollee pays the premium and is not covered under the policy or contract pursuant to continuation of benefits provisions applicable under federal and Commonwealth laws;
(3) bona fide association plans as set forth in this chapter, and
(4) converted policies as set forth in this chapter.
(b) For the purposes of this chapter, except as provided in subsection (c), issuers that are affiliated companies or that are eligible to file a consolidated income tax return shall be treated as one issuer, and any restrictions or limitations imposed by this chapter shall apply as if all individual health plans delivered or issued for delivery to residents of Puerto Rico by affiliated issuers were issued by one issuer.
(c) Any affiliated issuer who is a health services organization having a certificate of authority issued pursuant to the provisions of the Insurance Code of Puerto Rico or under this subtitle shall be considered to be a separate issuer for the purposes of this chapter.
(d) The Commissioner shall have the authority, pursuant to § 9008 of title, to impose sanctions. Likewise, the Commissioner shall have the power to prosecute administratively and judicially any violation of §§ 233-257 of this title.
History —Aug. 29, 2011, No. 194, added as § 10.040 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9165 - Restrictions related to rates and forms
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9165 - Restrictions related to rates and forms
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(a) Rates for individual health plans shall be subject to the provisions of the Affordable Care Act and the interpretive regulations adopted thereunder. Moreover, individual health plan issuers shall establish their rates based on the rating characteristics defined in this chapter and those established for such purposes by the Commissioner through policy letter.
(b) The Commissioner shall provide through policy letter the rules applicable to rate changes resulting from adjustments based on rating characteristics and benefit design.
(c) For purposes of this section, a preferred network plan shall not be considered a similar benefit design to that of a health plan that does not contain such a provision, if the restriction of benefits to network providers results in substantial differences in claim costs.
(d) Rates established pursuant to subsection (a)(1) of this section with respect to any individual health plan may not be changed more frequently than once a year. The premium charged to an enrollee may only be changed more than once within a twelve (12)-month period to reflect:
(1) Changes to the family composition of the enrollee, or
(2) changes to health insurance requested by the enrollee.
(e) The Commissioner may promulgate policy letters and rules to implement the provisions of this section and to assure that rating practices used by individual health plan issuers are consistent with the purposes of this chapter.
(f) As part of its solicitation and sales materials, the issuer shall make a reasonable disclosure, in connection with individual health plans, of all of the following:
(1) The manner in which rating characteristics are used to establish and adjust premium rates for an individual and his/her dependents;
(2) the issuer’s right to change premium rates and the factors, other than claim experience, that may affect changes in premium rates;
(3) the provisions relating to renewability of policy and contracts;
(4) the provisions relating to preexisting conditions, and
(5) all individual health plans offered by the insurer, the prices of the plan if available to the eligible person and the availability of the plans to the individual.
(g) Each issuer shall maintain at its principal place of business, and in digital format posted in its website and readily accessible to any person, a complete and detailed description of its rating and underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
(h) Each issuer shall file with the Commissioner annually on or before March 31 of each year, an actuarial certification certifying that the issuer is in compliance with this chapter and that the rating methods of the issuer are actuarially sound. The certification shall be in a form and manner, and shall contain such information, as specified by the Commissioner through policy letter. A copy of the certification shall be retained by the issuer at its principal place of business.
(i) An insurer shall make the information and documentation described in the above subsection available to the Commissioner upon request for his/her inspection. Except in cases of violations of any provision of this chapter, the information and documents required herein shall be considered proprietary and trade secret information and shall not be subject to disclosure by the Commissioner to persons outside of the Office of the Commissioner of Insurance, except as agreed to by the issuer or as ordered by a court with jurisdiction. Notwithstanding the provisions of this section, rates charged by the issuer shall not be considered as proprietary information.
(j) The individual health plan issuer shall file with the Commissioner the individual basic health plans in their different metal levels of coverage, following the procedure established in §§ 1101-1137 of this title and the format provided by the Commissioner through policy letter. The issuer may use the individual health insurance filed in accordance with this subsection ninety (90) days after the filing date, unless the Commissioner does not approve the use thereof.
(k) Issuers shall not modify an individual health plan approved with respect to an enrollee or his/her dependents through riders, endorsements, or surcharges based on their health status or claim experience nor shall exclude coverage or benefits related to specific diseases or medical services or conditions that would otherwise be covered under the health plan.
(l) The Commissioner at any time may, after providing notice and an opportunity for a hearing, disapprove the use of an individual health plan already approved if such plan fails to comply with the provisions of this chapter or the applicable federal legislation.
(m) Starting on January 1, 2014, no individual health plan shall deny, exclude or limit the benefits of a covered person based on preexisting conditions, regardless of the age of the enrollee.
History —Aug. 29, 2011, No. 194, added as § 10.050 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9166 - Renewability of coverage
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9166 - Renewability of coverage
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(a) An individual health plan issuer shall be renewable or shall continue in force the coverage for the enrollee and his/her dependent, at the option of the enrollee, and in accordance with the applicable federal regulations and legislation, except in the following cases:
(1) The enrollee has failed to pay premiums or contributions in accordance with the terms of the health plan or the issuer has not received timely premium payments.
(2) The enrollee or his/her representative has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact.
(3) The issuer elects to discontinue offering individual health plans delivered or issued in Puerto Rico; and, in addition, the issuer also:
(A) Provides written notice of its decision not to renew coverage at least ninety-five (95) days prior to the nonrenewal date, to the Commissioner.
(B) Provides written notice of its decision not to renew coverage at least ninety (90) days prior to the nonrenewal date, to all enrollees.
(4) If the Commissioner finds that the continuation of the coverage would not be in the best interests of the enrollees or would impair the issuer’s ability to meet its contractual obligations.
(5) The Commissioner finds that the product form is obsolete and is being replaced with comparable coverage and the issuer decides to discontinue offering that obsolete product form in Puerto Rico; in addition the issuer:
(A) Provides advance notice of its decision not to renew the obsolete product form to the Commissioner at least one hundred eighty-five (185) days prior to the nonrenewal date;
(B) provides notice of the decision not to renew coverage at least one hundred eighty (180) days prior to the nonrenewal date to all enrollees;
(C) offers to each enrollee of the obsolete product form the option to purchase all other health plans currently being offered by the issuer in Puerto Rico, and
(D) in exercising the option to discontinue that particular obsolete product form and in offering the option of coverage pursuant to paragraph (C), the issuer acts uniformly without regard to the claims experience or any health status-related factor of the enrollees or their beneficiaries who may be eligible for coverage.
(6) In the case of health plans that are made available in the individual market only through one or more bona fide associations, the membership of an individual in the association on the basis of which the coverage is provided ceases, provided the coverage is terminated under this paragraph uniformly without regard to any health status-related factor relating to the enrollee.
(7) In the case of a health plan that offers coverage through a preferred network plan, the enrollee no longer lives, resides, or works within the issuer’s established geographic service area, provided the coverage is terminated under this paragraph without regard to any health status-related factor relating to the enrollee.
(b)
(1) Any individual health plan issuer that elects to discontinue offering health plans pursuant to subsection (a)(3) shall be prohibited from writing new business in the individual market in Puerto Rico for a period of five (5) years beginning on the date the issuer ceased offering new coverage in Puerto Rico.
(2) In the case of a discontinuance under subsection (b)(1), the individual health plan issuer, as authorized or required by the Commissioner, may renew or not renew its existing business in the individual market in Puerto Rico.
(c) In the case of a health plan issuer doing business in one established geographic service area in Puerto Rico, the provisions of this section shall apply only to the issuer’s operations in that service area.
History —Aug. 29, 2011, No. 194, added as § 10.060 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9167 - Availability of coverage under a conversion privilege clause from a group health plan to a...
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9167 - Availability of coverage under a conversion privilege clause from a group health plan to a converted policy
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(a)
(1) As a condition of transacting insurance in Puerto Rico, individual health plan issuers shall offer approved basic health plans in its different metal levels of coverage to recently insured individuals who apply for an individual health plan and agree to make premium payments and satisfy the other reasonable requirements of such individual health plan.
(2) If the recently insured individual had qualifying previous coverage with benefits that are not similar to or exceed those provided under the Silver individual basic health plan, the issuer may offer the individual Bronze individual basic health plan to such recently insured individual, who converts his/her policy between enrollment periods, until the next enrollment period. During the enrollment period, the enrollee may elect his/her basic health plan of preference.
(3) An issuer shall not be required to issue an individual basic health plan in its different metal levels of coverage to a recently insured individual who:
(A) Does not apply for an individual basic health plan within thirty (30) days of a qualifying event or within thirty (30) days after becoming ineligible for qualifying existing coverage;
(B) is covered or is eligible for coverage under a health plan that provides health care coverage that is provided by an employer of the recently insured individual. A converted policy is not considered a benefit plan provided by an employer for purposes of this clause;
(C) is covered or is eligible for coverage under a health plan that provides healthcare coverage in which the spouse, father, mother, or guardian is enrolled or eligible to be enrolled, except if such health plan is the Government Health Plan known as “Mi Salud” or any other government plan administered by the Health Insurance Administration;
(D) for the duration of the coverage, in accordance with the prior individual health plan and which terminates after the effective date of the new coverage;
(E) is covered or is eligible for coverage, under any private or public health benefit arrangement, including a Medicare supplement policy or the Medicare program established under Title XVIII of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C. 301, as amended, or any other Federal or Commonwealth law, except for a Medicare-eligible individual for reasons other than age; or
(F) is covered or is eligible for any continued group health plan under Section 4980b of the U.S. Internal Revenue Code, 26 U.S.C. 4980b, Sections 601 through 608 of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, Sections 2201 through 2208 of the Public Health Services Act, as amended, or any other continued group health plan required by law.
(b) Upon an issuer notifying an enrollee, who is a resident of Puerto Rico, of a premium rate increase on the individual health plan, any other private health plan issuer may issue at the option of the enrollee, an individual basic health plan in its different metal levels of coverage, if the enrollee exercises his/her option within ninety (90) days of receiving the notification and the enrollee terminates existing coverage.
(c) Issuers shall not be required to offer coverage or accept applications, pursuant to subsection (a) of this section, from an eligible person who does not reside in the issuer’s established geographic service area.
(d) The Commissioner shall have the duty to establish through policy letter the procedures for the conversion of policies and the applicability and scope of this section for issuers that are not engaged in marketing policies in the individual market.
History —Aug. 29, 2011, No. 194, added as § 10.070 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9168 - Availability of coverage in the individual market—Federally defined eligible individual
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9168 - Availability of coverage in the individual market—Federally defined eligible individual
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(a) Notwithstanding the provisions of § 9167 of this title and subject to subsection (b) of this section and the applicable federal regulations, if an eligible individual who is a federally defined eligible individual applies for coverage under an individual health plan within sixty-three (63) days of termination of the prior creditable coverage, the individual health plan issuer may not:
(1) Decline to offer individual basic health plan, or deny enrollment of the individual, or
(2) with respect to the coverage, impose any preexisting condition exclusion, as such term is defined in this chapter, regardless of the age of the enrollee.
(b)
(1) An individual health plan issuer may elect to limit the coverage offered, if it offers at least two (2) different policy forms of individual basic health plan, both of which:
(A) Are designed for and meet the requirements of subsection (c) and comply with the provisions of § 9169 of this title and the applicable federal laws, as required in § 9005 of this title, and
(B) are made generally available to, and actively marketed by the issuer.
(2) For purposes of this subsection, policy forms that have different cost-sharing arrangements or different riders are considered to be different policy forms.
(c)
(1) An individual health plan issuer meets the requirements of subsection (b)(1)(A) if it offers a high-level and a low-level policy form, each of which:
(A) Includes benefits substantially similar to other individual health plans offered by the issuer in Puerto Rico, and
(B) is covered under a mechanism described in subsection (c)(4), relating to risk adjustment, risk spreading, or financial subsidization.
(2) For purposes of clause (1)(B), the following shall be considered a policy form:
(A) A low-level policy form, if the actuarial value of the benefits under the coverage is at least sixty percent (60%), but not greater than seventy percent (70%) of a weighted average, and
(B) a high-level policy form if:
(i) The actuarial value of the benefits under the coverage is at least fifteen percent (15%) greater than the actuarial value of the coverage described in paragraph (A) offered by the issuer in Puerto Rico, and
(ii) the actuarial value of the benefits under the coverage is at least eighty percent (80%), but not greater than ninety percent (90%) of a weighted average.
(3)
(A) For purposes of clause (2), the weighted average is the average actuarial value of the benefits provided, as determined by the issuer:
(i) Based on all the health plans issued by the issuer in the individual market during the previous year, weighted by enrollment for the different coverages, or
(ii) based on all the issuers in Puerto Rico in the individual market during the previous year, weighted by enrollment for the different coverages.
(B) The weighted average calculated under paragraph (A) shall not include health plans issued in accordance with this section.
(4) A mechanism meets the requirements of clause (1)(B) if:
(A) It provides for risk adjustment, risk spreading mechanism, or otherwise provides for some financial subsidization for federally defined eligible individuals, including through assistance to participating issuers, or
(B) it is a mechanism under which federally defined eligible individuals are provided a choice of coverage under all individual health plans the issuer otherwise has available.
(5)
(A) An election made under this subsection shall:
(i) Apply uniformly for all federally defined eligible individuals in Puerto Rico for that individual health plan issuer.
(ii) Is effective for policies offered during a period of at least two (2) years following the date of election.
(B) Pursuant to paragraph (A)(ii), after expiration of the initial election period and for the expiration of each subsequent election period, the issuer shall again make the elections in accordance with this subsection.
(6) For purposes of clause (2), the actuarial value of benefits provided under individual market coverage shall be calculated based on a standardized population and a set of standardized utilization and cost factors.
(d)
(1) A health plan issuer that offers coverage in the individual market through a preferred network plan may:
(A) Limit the individuals who may be enrolled under such coverage to those who live, reside, or work within the established geographic service area of such preferred network plan, and
(B) regarding the geographic service area of the preferred network plan, deny coverage to individuals who live, reside, or work within the established geographic service area, if the issuer demonstrates, to the satisfaction of the Commissioner, that:
(i) It will not have the capacity to deliver services adequately to additional individual enrollees because of its obligations to existing group or individual policy holders and individual enrollees, and
(ii) it is applying this clause uniformly to all individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are federally defined eligible individuals.
(2) An individual health plan issuer that cannot offer coverage in accordance with clause (1)(B), may not offer coverage in the individual market within the established geographic service area until:
(A) A period of one hundred eighty (180) days after the date of each coverage denial, or
(B) the date on which the issuer notifies the Commissioner that it can deliver services to specific individuals in the individual market, if such date is a later date than the date provided in paragraph (A).
(e)
(1) An individual health plan issuer shall not be required to provide coverage in the individual market to federally defined eligible individuals, under this subsection, if:
(A) For any period of time the Commissioner determines the individual health plan issuer does not have the financial reserves necessary to underwrite additional coverage, and
(B) the individual health plan issuer is applying this clause uniformly to all individuals in the individual market in Puerto Rico consistent with applicable Commonwealth law and without regard to any health status-related factor related to any individual and without regard to whether an individual is a federally defined eligible individual.
(2) An individual health plan issuer that denies coverage in accordance with clause (1) may not offer such coverage in the individual market until:
(A) A period of one hundred eighty (180) days after the date the coverage is denied, or
(B) the date on which the individual health plan issuer has demonstrated to the satisfaction of the Commissioner that it has sufficient financial reserves to underwrite additional coverage, if on a later date than the date provided in paragraph (A).
(f) The provisions of this section shall not be construed to require that an issuer offering health plans only in connection with group health plans or through one or more bona fide associations, or both, offer coverage in the individual market.
History —Aug. 29, 2011, No. 194, added as § 10.080 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9169 - Health plan standards
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9169 - Health plan standards
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The Commissioner shall provide through policy letter the form and level of coverage of the basic health plan in its different metal plans options for the individual market, so as to comply with the federal provisions and provide, at least, the Essential Health Benefit Package in accordance with § 9005 of this title, which shall be appropriately adjusted to reflect the individual market.
History —Aug. 29, 2011, No. 194, added as § 10.090 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9170/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9170 - Certification of creditable coverage
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9170 - Certification of creditable coverage
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(a) Individual health plan issuers offering individual health plans shall provide written certification of creditable coverage to all individuals in accordance with subsection (b).
(b) The certification of creditable coverage shall be provided:
(1) At the time an individual ceases to be covered under the health plan or otherwise becomes covered under a Consolidated Omnibus Budget Act of 1986 (COBRA) continuation provision;
(2) in the case of an individual who becomes covered under a Consolidated Omnibus Budget Act of 1986 (COBRA) continuation provision, at the time the individual ceases to be covered under that provision, and
(3) at the time a request is made on behalf of an individual if the request is made not later than twenty-four (24) months after the date of cessation of coverage described in clause (1) or (2), whichever is later.
(c) Individual health plan issuers may provide the certificate of creditable coverage required in subsection (b)(1) consistent with the applicable Consolidated Omnibus Budget Act of 1986 (COBRA) continuation provisions.
(d) The Commissioner shall establish through policy letters all the requirements that any certification of creditable coverage required under subsection (a) shall contain, subject to the applicable federal regulations regarding the content of such document, the requirements for issue, and the use thereof.
History —Aug. 29, 2011, No. 194, added as § 10.100 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9171/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9171 - Standards to assure fair marketing
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9171 - Standards to assure fair marketing
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(a)
(1) If an issuer denies individual health plan coverage to an eligible person on the basis of his/her health status or claims experience or that of his/her dependents, the issuer shall offer such person the opportunity to purchase an approved basic health plan in any of its different metal levels of coverage.
(2) Except as provided in §§ 9167 and 9168 of this title, and notwithstanding the provisions of clause (1), individual health plan issuers may not deny coverage to an applicant who is an eligible person or a federally defined eligible individual.
(b) Except as provided in subsection (c) of this section, no issuer, producer, or any other intermediary shall, directly or indirectly, engage in any of the following activities:
(1) Encourage or direct individuals to refrain from filing an application for coverage with the issuer because of the health status, claims experience, industry, occupation, or geographic location of the individual.
(2) Encourage or direct individuals to seek coverage from another issuer because of the health status, claims experience, industry, occupation, or geographic location of the individual.
(c) The provisions of subsection (b)(1) shall not apply with respect to information provided by an issuer or producer to an individual regarding the established geographic service area of the issuer or a preferred network provision of the issuer.
(d) Except as provided in subsection (e) of this section, no issuer shall, directly or indirectly, enter into any contract, agreement, or arrangement with a producer that provides for the compensation paid to a producer for the sale of a health plan to be varied because of the health status or permitted ratings characteristics of the individual or his/her dependents.
(e) Subsection (d) shall not apply with respect to a compensation arrangement to a producer on the basis of percentage of premium, provided that the percentage shall not vary because of the health status or other permitted rating characteristics of the individual or his/her dependents.
(f) Denial by an issuer of an application for coverage shall be in writing and shall state the reasons for the denial.
(g) A violation of this section by an issuer or a producer shall be an unfair trade practice under §§ 2701-2736 of this title.
(h) If an issuer enters into a contract, agreement, or other arrangement with a Third-party Administrator to provide administrative, marketing, or other services related to the offering of individual health plans in Puerto Rico, the Third- party Administrator shall be subject to this section as if it were an issuer.
(i) In addition to the provisions of this section, an issuer shall comply at all times with the applicable federal regulations.
History —Aug. 29, 2011, No. 194, added as § 10.110 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9172/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9172 - Health Plan Issuer Association
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9172 - Health Plan Issuer Association
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(a)
(1) A nonprofit corporation is hereby established to be known as the “Health Plan Issuer Association”. All issuers that underwrite individual health plans and basic health plans for PYMES employers in any of its different metal levels of coverage in Puerto Rico shall be members of this Association.
(2) The Association shall be organized as a corporation under the laws of the Commonwealth, shall operate under a plan of operation, and exercise its powers through a Board of Directors established in accordance with this section.
(b) The initial Board of Directors of the Association shall consist of seven (7) members appointed by the Commissioner as indicated below:
(1) Four (4) members shall be representatives of the four (4) largest domestic issuers, based on the corresponding health plan premiums in Puerto Rico as of the calendar year ending on December 31, 2013.
(2) Three (3) members shall be representatives of the next three (3) largest issuers in Puerto Rico, excluding Medicare supplement coverage premiums. If the issuer to be represented in accordance with this clause fails to appoint a representative, the board member shall be a representative of the next largest issuer that satisfies the criteria to belong to the Board.
(3) The Commissioner shall be an ex-officio member of the Board.
(c) After the initial term, board members shall be nominated and elected by the members of the Association, except for the Commissioner.
(d) Board members may be reimbursed from moneys of the Association for expenses incurred by them in connection with their functions as members of the Board, but shall not be otherwise compensated by the Association for their services.
(e)
(1) The Association shall submit to the Commissioner, for approval, a plan of operation for the Association and any amendments to the articles of incorporation as necessary and appropriate to assure the fair, reasonable, and equitable administration of the Association.
(2) The plan shall provide for the sharing of losses in connection with individual basic health plans and basic health plans for PYMES employers, in any of its different metal levels of coverage, if any, on an equitable and proportional basis among the members of the Association that underwrite any of such plans, as appropriate.
(3)
(A) If the association fails to submit a suitable plan of operation within one hundred eighty (180) days after the appointment of the Board of Directors, the Commissioner shall adopt the plan of operation as necessary to implement this subsection.
(B) The plan of operation shall remain in effect until modified by the Commissioner or superseded by a plan submitted by the Association and approved by the Commissioner.
(4) Furthermore, the plan of operation shall include requirements for the following:
(A) The handling and accounting of assets and funds of the Association.
(B) The amount and method for reimbursing the expenses of Board members.
(C) The date and the regular times and places for meetings of the Board of Directors.
(D) The records to be kept with respect to all financial transactions and annual financial reports to be filed with the Commissioner.
(E) The procedure for selecting the Board of Directors.
(F) Additional provisions as necessary and proper for the execution of the powers and duties of the Association.
(f) The plan of operation may provide that the powers and duties of the Association may be delegated to a person who shall perform functions similar to those of the Association. A delegation of powers and duties in accordance with this subsection shall take effect only upon the approval of the Board of Directors.
(g)
(1) The Association shall have the general powers and authority established in this section, which shall be executed and, in accordance with the plan of operation approved by the Commissioner under subsection (e) of this section.
(2) In addition to the general powers and authority provided in this section and the plan of operation, the Association may:
(A) Enter into such contracts as are necessary or proper to implement this chapter;
(B) sue or be sued, which includes taking any legal action necessary or proper for recovery of any attributable loss corresponding to the members of the Association or other individual, whether on behalf of or against such member or individual;
(C) appoint legal, actuarial, and other committees from among members, to provide technical assistance in the operation of the Association, including the hiring of independent consultants, as necessary, and
(D) to perform any other functions within the authority of the Association.
(h) At the close of each calendar year, the Association, in conjunction with the Commissioner, shall require each issuer to report the amount of earned premiums and the associated paid losses for all individual basic health plans and basic health plans for PYMES employers, in any of its different metal levels of coverage that were issued by the issuer. The amounts included in such report shall be certified by an official of the issuer.
(i) The Board shall establish the procedures for collections, make assessments, and collect and make distributions, so that issuers of individual basic health plans and basic health plans for PYMES employers, in any of its different levels of coverage, receive the same ratio of paid claims to earned premiums on their individual basic health plan and basic health plans for PYMES employers assumed as the aggregate of all issuers of these type of health plans in Puerto Rico.
(j) If the island-wide aggregate ratio of paid losses to earned premiums is greater than ninety percent (90%), the dollar difference between ninety percent (90%) of earned premiums and the paid claims shall be treated as attributable loss.
(k) The attributable loss plus the necessary operating expenses for the Association, plus any additional expense as provided through regulations shall be assessed by the Association to all members in proportion to their respective shares of total individual basic health plan premiums and/or basic health plans for PYMES employers premiums received during the immediately preceding calendar year or on any other equitable method as provided in the plan of operation. In sharing losses, the Association may abate or defer any portion of the assessment of a member of the Association if, in the opinion of the Board, payment of the assessment would endanger the ability of such member to fulfill his/her contractual obligations. The Association may also provide for an initial or interim assessment against members of the Association to meet the operating expenses thereof until the next calendar year is complete.
(l) The Board shall ensure that the procedures for collecting and distributing assessments are as efficient as possible for issuers. The Board may establish procedures to combine or offset the assessment from and the distribution due to the issuer.
(m) Issuers may request the Board of the Association to seek remedy from writing a disproportionate share of individual basic health plan or health plans for PYMES employers with respect to the total premium written in Puerto Rico for health plans. If the Board determines that the issuer has written a significantly disproportionate share, the issuer may be compensated by paying an additional fee which shall not exceed two percent (2%) of earned premiums of basic health plan or health plans for PYMES employers, as appropriate for such issuer or by petitioning the Commissioner for remedy.
(n) If the Commissioner determines that the acceptance of the offer of individual basic health plan or health plan for PYMES employers of coverage by an individual pursuant to this chapter would place the issuer in a financially impaired condition, the Commissioner shall not require the issuer to offer such coverage or accept applications for the period of time the financial impairment is deemed to exist. The Commissioner may establish through policy letter the definition of “disproportionate share”.
History —Aug. 29, 2011, No. 194, added as § 10.120 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9173/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9173 - Participation in employer-sponsored health plans
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9173 - Participation in employer-sponsored health plans
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A health plan sponsored and paid by an employer qualified under the Employee Retirement Income Security Act of 1974 (ERISA), as amended, specifically basic health plans for PYMES employers in any of its different metal levels of coverage may participate in the Health Plan Issuer Association established in § 9172 of this title in accordance with the plan of operation and subject to the terms and conditions to be adopted by the Board of the Association.
History —Aug. 29, 2011, No. 194, added as § 10.130 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9174/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9174 - Special rules related to converted policies
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9174 - Special rules related to converted policies
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(a) Upon the approval of the basic health plans in the different metal levels of coverage in accordance with § 9169 of this title, all issuers required to offer a converted policy to an individual, pursuant to the provisions of this Code, may offer as a converted policy a choice of the individual basic health plans only.
(b) If an issuer offers two or more options of individual basic health plan as a conversion coverage in accordance with subsection (a), then the issuer shall be eligible to receive distributions pursuant to the Health Plan Association for the individual basic converted policies in accordance with § 9172 of this title.
(c) If an issuer offers two or more options of individual basic health plan as a conversion coverage in accordance with subsection (a), then the individual with a converted policy issued before the effective date of the requirement under subsection (a) shall be entitled to elect an individual basic health plan as a substitute converted policy at each annual renewal of the converted policy.
(d) The Commissioner shall provide through policy letter the rules to rate converted policies in accordance with this chapter, and to rate converted policies that provide medical coverage similar to or exceeding that of health plans.
(e) The Commissioner shall issue and promulgate policy letters, as well as regulations as necessary for the implementation of this section.
History —Aug. 29, 2011, No. 194, added as § 10.140 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-108/9175/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175)›§ 9175 - Guaranteed availability of individual health plans
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9175 - Guaranteed availability of individual health plans
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(a) Subject to the applicable federal legislation and regulations, all issuers shall allow individuals to enroll in at least the individual basic health plans they have available in the individual market from October 1, 2013 to March 31, 2014, without risk assessment. For subsequent years, the enrollment period shall be from October 1st to December 31st of each year. In the case of health plan renewal, if the enrollee fails to renew the individual basic health plan during the enrollment period set forth in this subsection, he/she may renew it provided that such renewal is made within thirty (30) days from the due date of the enrollment period set forth herein.
(b) For health plan applications received by the issuer before December 15, the effective date of coverage shall be January 1 of the following year. After December 31, if the issuer receives an application between the 1st and 15th day of a month, coverage shall be effective on the first day of the following month. If the issuer receives an application between the 16th and the 31st day of a month, coverage shall be effective on the first day of the second month after the application was received. For purposes of this subsection, the aforementioned health plan applications are those processed within the enrollment periods set forth in subsection (a) of this section.
(c) Notwithstanding the foregoing, at any time during the year, an issuer shall offer individual basic health plans available in the individual market only to enrollees who:
(1) Exercise their conversion rights in the individual market with the same issuer that offered coverage under his/her most recent health plan.
(2) Had insurance issued by another issuer and meet the following criteria:
(A) Has been uninsured for sixty-three (63) days.
(B) His/her most recent coverage had a group health plan.
(C) Has been covered under a health plan for the past eighteen (18) months. During such time, such individual may have been covered under individual or group health plan.
(D) The most recent coverage was not terminated due to nonpayment or fraud.
(E) If the individual was eligible for coverage under the Consolidated Omnibus Budget Act of 1986 (COBRA), elected the same and exhausted it; policy letter.
(F) Lost eligibility to Mi Salud plan.
(3) Meet any other criteria provided by the Commissioner through [sic]
(d) In addition to the provisions of subsection (c) of this section, any individual whose coverage has terminated under group or individual market health plan due to bankruptcy, dissolution or revocation of the license of an issuer who issued such insurance policy shall also be eligible, provided that such individual files an application to a new issuer within sixty-three (63) days after bankruptcy, dissolution or revocation of license of the issuer is filed.
(e) The Commissioner shall establish through policy letters the procedures for enrollment periods in the event that the applicant for individual health plan elects not to enroll during the enrollment period established in subsection (a) of this section, as well as the methods to advise citizens on the terms and effects of not enrolling during such periods.
(f) Any issuer may require an applicant for group or individual health plan to fill out a medical questionnaire whereby information about preexisting conditions, as well as current prescriptions taken and care received to control a health condition, and the information of the primary care provider treating such condition. The information provided in such questionnaire shall be used solely and exclusively by the issuer for the purpose of registering the enrollee in an established program to manage diseases.
History —Aug. 29, 2011, No. 194, added as § 10.150 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-110/9201/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204)›§ 9201 - Title
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9201 - Title
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This chapter shall be known and may be cited as the chapter on the Prohibition on the Use of Discretionary Clauses.
History —Aug. 29, 2011, No. 194, § 12.010, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-110/9202/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204)›§ 9202 - Purpose
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9202 - Purpose
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The purpose of this chapter is to assure that health insurance benefits and disability income protection coverage are contractually guaranteed so as to prevent the conflict of interest that occurs when health insurance organizations or issuers have discretionary authority to decide what benefits are due. Nothing in this chapter shall be construed as imposing any requirement or duty on any person other than a health insurance organization or issuer that offers disability income protection coverage.
History —Aug. 29, 2011, No. 194, § 12.020, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-110/9203/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204)›§ 9203 - Definitions
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9203 - Definitions
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(a) Disability income protection coverage.— Is a policy, contract, certificate or agreement that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination of them.
(b) Healthcare services.— Means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
History —Aug. 29, 2011, No. 194, § 12.030, eff. 180 days after Aug. 29, 2011.
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https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-110/9204/
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PR
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Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SIX - Insurance (§§ 101 — 10377)›Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377)›Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204)›§ 9204 - Discretionary clauses prohibited
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2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9204 - Discretionary clauses prohibited
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(a) No policy, contract, certificate or agreement offered or issued in Puerto Rico by a health insurance organization or issuer to provide, deliver, arrange for, pay for or reimburse any of the costs of healthcare services may contain a provision purporting to reserve discretion to health insurance organizations or issuers to interpret the terms of the contract, or to provide standards of interpretation or review that are inconsistent with the laws of Puerto Rico. An adverse determination by a health insurance organization or issuer, as well as disputes or controversies that may arise between a health insurance organization or issuer and a covered person or enrollee, shall be subject to the internal and external review procedures established in this Code.
(b) No policy, contract, certificate or agreement offered or issued in Puerto Rico providing for disability income protection coverage may contain a provision purporting to reserve discretion to the insurer to interpret the terms of the contract, or to provide standards of interpretation or review that are inconsistent with the laws of Puerto Rico.
History —Aug. 29, 2011, No. 194, § 12.040, eff. 180 days after Aug. 29, 2011.
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