Subset (2)

all_codes · 1.84M rows

Split (1)

train · 1.84M rows

Subsets and Splits

Unemployment Word Count by State

Calculates the total word count of documents related to unemployment in each state, revealing insights into the volume of unemployment-related content by location.

CO Title 8 Word Count

Calculates the total number of words in the content of entries related to 'Title 8' in Colorado, providing insight into the volume of text data available for that specific category and state.

url stringlengths 42 388	state stringclasses 50 values	path stringlengths 83 10.4k	title stringlengths 34 2.24k	content stringlengths 0 2.39M
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9507/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9507 - Exhaustion of internal grievance process	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9507 - Exhaustion of internal grievance process	(a) (1) Except as provided in subsection (b) of this section, a request for an external review shall not be made until the covered person or enrollee has exhausted the health insurance organization or issuer's internal grievance process. (2) For purposes of this section, the health insurance organization or issuer's internal grievance process shall be considered to have been exhausted, if the covered person or enrollee: (A) Has filed a grievance pursuant to § 9397 of this title, and (B) the covered person or enrollee has not received a written decision on the grievance from the health insurance organization or issuer within thirty (30) days following the date he/she filed the grievance, unless an extension or delay has been agreed upon. (3) Notwithstanding the above clause (2) of this subsection, a covered person or enrollee may not make a request for an external review of an adverse determination involving a retrospective review determination made pursuant to §§ 9421–9434 of this title until he/she has exhausted the health insurance organization or issuer's internal grievance process. (b) (1) (A) At the same time a covered person or enrollee files a request for an expedited review of a grievance as set forth in § 9400 of this title, he/she may file a request for an expedited external review, in accordance with any of the following: (i) Under § 9509 of this title, if the covered person or enrollee has a medical condition where the timeframe for completion of an expedited review of the grievance would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, or (ii) under § 9510 of this title, if the adverse determination involves a denial of coverage based on a determination that the recommended or requested healthcare service or treatment is experimental or investigational and the covered person or enrollee's treating physician certifies in writing that healthcare service or treatment would be significantly less effective if not promptly initiated. (B) Upon receipt of a request for an expedited external review under paragraph (A) of this clause, the independent review organization designated to conduct the external review shall determine whether the covered person or enrollee shall be required to complete the expedited internal review process first. (C) If the independent review organization determines that the covered person or enrollee shall complete the expedited internal review process first, it shall immediately notify the covered person or enrollee of this determination and that it will not proceed with the expedited external review until completion of the expedited grievance review process. (2) A request for an external review of an adverse determination may be made before the covered person or enrollee has exhausted the health insurance organization or issuer's internal grievance procedures, provided that the health insurance organization or issuer agrees to waive the exhaustion requirement. (c) If the requirement to exhaust the health insurance organization or issuer's internal grievance procedures is waived, the covered person or enrollee may file a request in writing for a standard external review. History —Aug. 29, 2011, No. 194, added as § 28.070 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9508/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9508 - Standard external review	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9508 - Standard external review	(a) (1) Not later than one hundred and twenty (120) days after the date of receipt of a notice of an adverse determination or final adverse determination, a covered person or enrollee may file a request for an external review with the Commissioner. (2) Within one (1) business day after the date of receipt of a request for external review, the Commissioner shall send a copy of the request to the health insurance organization or issuer involved. (b) Within five (5) business days following the date of receipt of the copy of the external review request, the health insurance organization or issuer shall complete a preliminary review of the request to determine whether: (1) The individual is or was a covered person or enrollee in the health plan at the time the healthcare service was requested or, in the case of a retrospective review, was a covered person or enrollee in the health plan at the time the healthcare service was provided; (2) the healthcare service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person or enrollee's health plan, but for a determination by the health insurance organization or issuer that the healthcare service is not covered because it does not meet the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness; (3) the covered person or enrollee has exhausted the health insurance organization or issuer's internal grievance process, unless it is not required to exhaust such internal grievance process pursuant to § 9507 of this title, and (4) the covered person or enrollee has provided all the information and forms required by the Commissioner to process an external review, including the health information release form provided under § 9505(b)(3) of this title. (c) (1) Not later than one (1) business day after completion of the preliminary review, pursuant to subsection (b) of this section, the health insurance organization or issuer shall notify the Commissioner and the covered person or enrollee in writing whether: (A) The request is complete, and (B) the request is eligible for external review. (2) If the request: (A) Is not complete, the health insurance organization or issuer shall provide a notice of initial determination to the covered person or enrollee and the Commissioner in writing and include what information or materials are needed to make the request complete, or (B) is not eligible for external review, the health insurance organization or issuer shall provide a notice of initial determination to the covered person or enrollee and the Commissioner in writing and include the reasons for its ineligibility. (3) (A) The Commissioner may specify the form and content of the notice of initial determination referred to in clause (2) of this subsection. (B) If the health insurance organization or issuer determines, as a result of the preliminary review conducted pursuant to subsection (b) of this section that a request is not eligible for external review, the notice provided for such purposes to the covered person or enrollee shall include a statement informing the covered person or enrollee that the health insurance organization or issuer has made a determination of ineligibility and that it may be appealed to the Commissioner. (4) (A) The Commissioner may determine that a request is eligible for external review under subsection (b) of this section notwithstanding a health insurance organization or issuer's initial determination to the contrary. (B) The decision of the Commissioner that a request is eligible for external review, after the initial determination of the health insurance organization or issuer to the contrary, shall be made in accordance with the terms of the health plan and shall be subject to all applicable provisions of this chapter. (d) (1) Not later than one (1) business day after the date of receipt of the notice, whenever the Commissioner receives a notice that a request is eligible for external review, he/she shall: (A) Assign an independent review organization to conduct the external review and notify the health insurance organization or issuer of the name of the assigned independent review organization, and (B) Notify in writing the covered person or enrollee of the request's eligibility and acceptance for external review. (2) In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the health insurance organization or issuer's utilization review process or internal grievance process. (3) The Commissioner shall include in the notice of request acceptance for external review provided to the covered person or enrollee a statement that he/she may submit in writing to the assigned independent review organization within five (5) business days following the date of receipt of the notice provided, additional information that the independent review organization shall consider when conducting the external review. The independent review organization is not required to, but may, accept and consider additional information submitted after five (5) business days, as provided herein. (e) (1) Not later than five (5) business days after the date of receipt of the notice, the health insurance organization or issuer shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination subject to external review. (2) Except as provided in clause (3) of this subsection, failure by the health insurance organization or issuer to provide the documents and information required within five (5) business days as provided in clause (1) of this subsection, shall not delay the conduct of the external review. (3) (A) If the health insurance organization or issuer fails to provide the documents and information within five (5) business days as provided in clause (1) of this subsection, the independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination subject to external review. (B) Not later than one (1) business day after making the decision to reverse the adverse determination or final adverse determination subject to external review, on the grounds provided in paragraph (A) of this clause, the independent review organization shall notify the covered person or enrollee, the health insurance organization or issuer, and the Commissioner. (f) (1) The independent review organization shall review all of the information and documents received from the health insurance organization or issuer and any other information submitted in writing by the covered person or enrollee. (2) If the independent review organization receives information submitted by the covered person or enrollee, it shall forward such information to the health insurance organization or issuer involved not later than one (1) business day upon receipt of the information. (g) (1) Upon receipt of the information pursuant to subsection (f)(2) of this section, the health insurance organization or issuer may reconsider its adverse determination or final adverse determination that is the subject of the external review. (2) Reconsideration by the health insurance organization or issuer of its adverse determination or final adverse determination shall not delay or terminate the external review. (3) The external review may only be terminated if the health insurance organization or issuer decides, upon completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the healthcare service that is the subject of the adverse determination or final adverse determination. (4) (A) Within one (1) business day after making the decision to reverse its adverse determination or final adverse determination, the health insurance organization or issuer shall notify the covered person or enrollee, the independent review organization, and the Commissioner in writing of its decision. (B) The independent review organization shall terminate the external review upon receipt of the notice from the health insurance organization or issuer sent pursuant to paragraph (A) of this clause. (h) In addition to the documents and information provided pursuant to subsection (e)(1) of this section, the independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision: (1) The covered person or enrollee's medical records; (2) the covered person or enrollee's attending healthcare professional's recommendation; (3) consulting reports from appropriate healthcare professionals and other documents submitted by the health insurance organization or issuer, the covered person or enrollee, or the covered person or enrollee's treating provider; (4) the terms of coverage under the covered person or enrollee's health plan; (5) the most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional and medical societies, boards and associations; (6) any applicable clinical review criteria developed and used by the health insurance organization or issuer or utilization review organization in making an adverse determination or final adverse determination, and (7) the opinion of any independent review organization's clinical reviewer after considering the documents listed in clauses (1)–(6) of this subsection. (i) (1) Not later than forty-five (45) days after the date of receipt of the request for an external review, the independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination subject of the review. The written notice shall be provided to: (A) The covered person or enrollee. (B) The health insurance organization or issuer. (C) The Commissioner. (2) The independent review organization shall include in the written notice: (A) A general description of the reason for the request for external review; (B) the date the independent review organization received the assignment from the Commissioner to conduct the external review; (C) the date the external review was conducted; (D) the date of its decision; (E) the principal reason or reasons for its decision, including what applicable, if any, evidence-based standards were a basis for its decision; (F) the rationale for its decision, and (G) references to the evidence or documentation, including the evidence-based standards, considered in reaching its decision. (3) Upon receipt of a notice from the independent review organization of a decision reversing the adverse determination or final adverse determination, the health insurance organization or issuer immediately shall approve coverage or payment of the service or benefit that was the subject of the review. (j) The assignment by the Commissioner of an independent review organization to conduct an external review in accordance with this chapter shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the healthcare service that is the subject of the adverse determination or final adverse determination being reviewed and other circumstances, including potential conflict of interests. History —Aug. 29, 2011, No. 194, added as § 28.080 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9509/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9509 - Expedited external review	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9509 - Expedited external review	(a) Except as provided in subsection (f) of this section, a covered person or enrollee may make a request for an expedited external review with the Commissioner at the time he/she receives: (1) An adverse determination, if: (A) The adverse determination involves a medical condition of the covered person or enrollee for which the timeframe for completion of an expedited internal review as provided in § 9400 of this title, would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, and (B) the covered person or enrollee has filed a request for an expedited review of a grievance involving an adverse determination as set forth in § 9400 of this title, or (2) A final adverse determination, if: (A) The covered person or enrollee has a medical condition where the timeframe for completion of a standard external review pursuant to § 9508 of this title would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, or (B) the final adverse determination concerns an admission, availability of care, continued stay or healthcare service for which the covered person or enrollee received emergency services, but has not been discharged from a facility. (b) (1) Upon receipt of a request for an expedited external review, the Commissioner immediately shall send a copy of the request to the health insurance organization or issuer involved. (2) Immediately upon receipt of the request for expedited external review, the health insurance organization or issuer shall determine whether the request meets the reviewability requirements set forth in § 9508 of this title, and immediately notify the Commissioner and the covered person or enrollee of its eligibility determination. (3) (A) The Commissioner may specify the form and content of the health insurance organization or issuer's notice of initial determination under clause (2) of this subsection. (B) If the health insurance organization or issuer determines, as a result of the preliminary review conducted in accordance with clause (2) of this subsection, that an external review request is ineligible for external review, the notice provided to the covered person or enrollee shall include a statement informing him/her that the health insurance organization or issuer's determination of ineligibility may be appealed to the Commissioner. (4) (A) The Commissioner may determine that a request is eligible for external review notwithstanding a health insurance organization or issuer's initial determination to the contrary. (B) In making a determination that a request is eligible for external review notwithstanding a health insurance organization or issuer's initial determination to the contrary, the Commissioner's decision shall be made in accordance with the terms of the covered person or enrollee's health plan and shall be subject to all applicable provisions of this chapter. (5) Upon receipt of the notice of the health insurance organization or issuer that the request meets the reviewability requirements, the Commissioner shall immediately assign an independent review organization to conduct the expedited external review. The Commissioner shall immediately notify the health insurance organization or issuer of the name of the assigned independent review organization and notify in writing the covered person or enrollee that a request is eligible for review and was accepted for expedited external review. (6) In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the health insurance organization or issuer's utilization review process or internal grievance process. (c) Upon receipt of the notice from the Commissioner of the name of the assigned independent review organization, the health insurance organization or issuer shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination subject to expedited external review electronically or by any other available expeditious method. (d) In addition to the documents and information set forth in subsection (c) of this section, the independent review organization, to the extent the information or documents are available and considers them appropriate, shall consider the following in reaching a decision: (1) The covered person or enrollee's pertinent medical records; (2) the covered person or enrollee's attending healthcare professional's recommendation; (3) consulting reports from appropriate healthcare professionals and other documents submitted by the health insurance organization or issuer, covered person or enrollee, or his/her treating provider; (4) the terms of coverage under the covered person or enrollee's health plan; (5) the most appropriate practice guidelines, which shall include evidence-based standards, and may include any other practice guidelines developed by the federal government, national or professional and medical societies, boards and associations; (6) any applicable clinical review criteria developed and used by the health insurance organization or issuer or utilization review organization in making adverse determinations, and (7) the opinion of any independent review organization's clinical reviewer after considering the documents listed in clauses (1)–(6) above. (e) (1) As expeditiously as the covered person or enrollee's medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review, the assigned independent review organization shall: (A) Make a decision to uphold or reverse the adverse determination or final adverse determination subject of review, and (B) notify the covered person or enrollee, the health insurance organization or issuer, and the Commissioner of the decision. (2) If the notice of the decision of the independent review organization is not initially made in writing, within forty-eight (48) hours after the determination, the independent review organization shall: (A) Provide written confirmation of the decision to the covered person or enrollee, the health insurance organization or issuer, and the Commissioner, and (B) include in the written notice the information set forth in § 9508(i)(2) of this title. (3) If the decision of the independent review organization reverses the adverse determination or final adverse determination subject to review, the health insurance organization or issuer immediately shall approve the coverage or payment for the service or benefit that was the subject of the expedited external review. (f) An expedited external review may not be available when the adverse determination or final adverse determination was a result of a retrospective review. (g) The assignment by the Commissioner of an independent review organization to conduct an expedited external review in accordance with this chapter shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the healthcare service that is the subject of the adverse determination or final adverse determination under review and other circumstances, including potential conflict of interests. History —Aug. 29, 2011, No. 194, added as § 28.090 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9510/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9510 - External review of experimental or investigational treatment adverse determinations	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9510 - External review of experimental or investigational treatment adverse determinations	(a) (1) Not later than one hundred twenty (120) days after the date of receipt of a notice of an adverse determination or final adverse determination that involves a denial of a healthcare service or treatment recommended or requested based on a determination that such service or treatment is experimental or investigational, a covered person or enrollee may file a request for external review with the Commissioner. (2) (A) A covered person or enrollee may make an oral request for an expedited external review of the adverse determination or final adverse determination that involves a denial of a healthcare service or treatment recommended or requested based on a determination that such service or treatment is experimental or investigational, provided that the covered person or enrollee's treating physician certifies, in writing, that the recommended or requested healthcare service or treatment that was denied would be significantly less effective if not promptly initiated. (B) Upon receipt of a request for an expedited external review pursuant to paragraph (A) above, the Commissioner immediately shall notify the health insurance organization or issuer involved of the aforementioned request. (C) (i) Upon receipt of a copy of the request, the health insurance organization or issuer immediately shall determine whether the request meets the reviewability requirements of subsection (b)(2) of this section and notify the Commissioner and the covered person or enrollee of its determination indicating whether the request is eligible for external review. (ii) The Commissioner may specify the form and content of the initial determination referred to in subparagraph (i) above. (iii) If the health insurance organization or issuer determines, as a result of the preliminary review conducted in accordance with subparagraph (i) of this paragraph, that the request is ineligible for external review, the notice provided to the covered person or enrollee shall include a statement informing him/her that the health insurance organization or issuer's determination of ineligibility may be appealed to the Commissioner. (D) (i) The Commissioner may determine that a request is eligible for external review notwithstanding a health insurance organization or issuer's initial determination to the contrary. (ii) The Commissioner shall make a determination that a request is eligible for external review, notwithstanding a health insurance organization or issuer's initial determination to the contrary, in accordance with the terms of the covered person or enrollee's health plan and shall be subject to all applicable provisions of this chapter. (E) Upon receipt of the notice from the health insurance organization or issuer that the expedited external review request meets the reviewability requirements, the Commissioner immediately shall assign an independent review organization to conduct an expedited external review and notify the health insurance organization or issuer of the name of the assigned independent review organization, and notify in writing the covered person or enrollee that his/her request is eligible and was accepted for expedited external review. (F) Upon receipt of the notice from the Commissioner of the name of the assigned independent review organization, the health insurance organization or issuer shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination subject to expedited external review electronically or by any other available expeditious method. (b) (1) Except for a request for an expedited external review made pursuant to subsection (a)(2) of this section, not later than one (1) business day after the date of receipt of the request for an external review that involves a denial of a healthcare service or treatment recommended or requested based on a determination that such service or treatment is experimental or investigational, the Commissioner shall notify the health insurance organization or issuer involved with a copy of the request. (2) Upon receipt of the notice of the request for external review, the health insurance organization or issuer shall have five (5) businesses days to conduct a preliminary review of the request to determine whether: (A) The individual is or was a covered person or enrollee in the health plan at the time the denied healthcare service or treatment was recommended or requested or, in the case of a retrospective review, was a covered person or enrollee in the health plan at the time the healthcare service or treatment was provided. (B) The recommended or requested healthcare service or treatment that is the subject of the adverse determination or final adverse determination: (i) Is a covered benefit under the covered person or enrollee's health plan except for the health insurance organization or issuer's determination that the service or treatment is experimental or investigational, and (ii) is not explicitly listed as an excluded benefit under the covered person or enrollee's health plan. (C) The covered person or enrollee's treating physician has certified that one of the following situations is applicable: (i) Standard healthcare services or treatments have not been effective in improving the condition of the covered person or enrollee; (ii) standard healthcare services or treatments are not medically appropriate for the covered person or enrollee, or (iii) there is no available standard healthcare service or treatment covered by the health plan that is more beneficial than the recommended or requested healthcare service or treatment. (D) The covered person or enrollee's treating physician: (i) Has recommended a healthcare service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person or enrollee, in the physician's opinion, than any available standard healthcare services or treatments, or (ii) the covered person or enrollee's treating physician, who is qualified to practice in the area of medicine appropriate to treat the health condition in question, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the healthcare service or treatment requested by the covered person or enrollee is likely to be more beneficial than any available standard healthcare services or treatments. (E) The covered person or enrollee has exhausted the health insurance organization or issuer's internal grievance process, unless he/she is not required to exhaust such remedy pursuant to § 9507 of this title. (F) The covered person or enrollee has provided all the information and forms required by the Commissioner that are necessary to process an external review, including the release form provided under § 9505(b)(3) of this title. (c) (1) Not later than one (1) business day after completion of the preliminary review pursuant to subsection (b)(2) of this Section, the health insurance organization or issuer shall notify the Commissioner and the covered person or enrollee in writing whether: (A) The request is complete, and (B) the request is eligible for external review. (2) If the request: (A) Is not complete, the health insurance organization or issuer shall inform in writing the Commissioner and the covered person or enrollee and include what information or materials are needed to make the request complete, or (B) is not eligible for external review, the health insurance organization or issuer shall inform the covered person or enrollee and the Commissioner in writing and include the reasons for its ineligibility. (3) (A) The Commissioner may specify the form and content of the health insurance organization or issuer's notice of initial determination referred to in clause (2) of this subsection. (B) If the health insurance organization or issuer determines, as a result of the preliminary review conducted in accordance with subsection (b)(2) of this section, that an external review request is ineligible for external review, the notice provided to the covered person or enrollee shall include a statement informing him/her that the health insurance organization or issuer's determination of ineligibility may be appealed to the Commissioner. (4) (A) The Commissioner may determine that a request is eligible for external review notwithstanding a health insurance organization or issuer's initial determination to the contrary. (B) In making a determination that a request is eligible for external review notwithstanding a health insurance organization or issuer's initial determination to the contrary, the Commissioner's decision shall be made in accordance with the terms of the health plan and shall be subject to all applicable provisions of this chapter. (5) Whenever a health insurance organization or issuer determines that a request for external review is eligible for such purposes, it shall notify the Commissioner and the covered person or enrollee of such determination. (d) (1) Not later than one (1) business day after the receipt of the notice from the health insurance organization or issuer that the external review request is eligible for external review, the Commissioner shall: (A) Assign an independent review organization to conduct the external review and notify the health insurance organization or issuer of the name of the assigned independent review organization, and (B) notify in writing the covered person or enrollee of the request's eligibility and acceptance for external review. (2) The Commissioner shall include in the notice of request acceptance for external review provided to the covered person or enrollee a statement that the covered person or enrollee may submit in writing to the independent review organization within five (5) business days following the date of receipt of the notice, any additional information that the independent review organization shall consider when conducting the external review. The independent review organization shall not be required to, but may, accept and consider additional information submitted after the five (5) business days provided herein. (3) Not later than one (1) business day after the receipt of the notice of assignment to conduct the external review, the independent review organization shall: (A) Select one (1) or more clinical reviewers, as appropriate, to conduct the external review; and (4) (A) In selecting clinical reviewers, the independent review organization shall select physicians or other healthcare professionals who meet the minimum qualifications described in § 9513(b) of this title and, through clinical experience in the past three (3) years, are experts in the treatment of the covered person or enrollee's condition and knowledgeable about the recommended or requested healthcare service or treatment. (B) Neither the covered person or enrollee nor the health insurance organization or issuer shall choose or control the choice of the physicians or other healthcare professionals to be selected as clinical reviewers to conduct the external review. (5) In accordance with subsection (h) of this section, each clinical reviewer shall provide a written opinion to the independent review organization on whether the recommended or requested healthcare service or treatment should be covered. (6) In reaching an opinion, clinical reviewers shall not be bound by any decisions or conclusions reached during the health insurance organization or issuer's utilization review process or internal grievance process. (e) (1) Not later than five (5) business days after the date of receipt of the notice on the designated utilization review organization, the health insurance organization or issuer shall provide the documents and any information considered in making the adverse determination or the final adverse determination subject of the review. (2) Except as provided in clause (3) of this subsection, failure by the health insurance organization or issuer to provide the documents and information within five business (5) days as specified in s clause (1) of this subsection, shall not delay the conduct of the external review. (3) (A) If the health insurance organization or issuer has failed to provide the required documents and information within five (5) business days as specified in clause (1) of this subsection, the independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination subject of the review. (B) If the independent review organization decides to reverse the adverse determination or the final adverse determination under paragraph (A) of this clause, it shall immediately notify the covered person or enrollee, the health insurance organization or issuer, and the Commissioner. (f) (1) Each clinical reviewer shall review all of the information and documents received from the health insurance organization or issuer and any other information submitted in writing by the covered person or enrollee. (2) If the independent review organization receives any information from the covered person or enrollee, the independent review organization shall forward the information to the health insurance organization or issuer not later than one (1) business day after the receipt thereof. (g) (1) Upon receipt of the information provided in subsection (f)(2) of this section, the health insurance organization or issuer may reconsider its adverse determination or final adverse determination that is the subject of the external review. (2) Reconsideration by the health insurance organization or issuer of its adverse determination or final adverse determination shall not delay or terminate the external review. (3) The external review may terminated only if the health insurance organization or issuer decides, upon completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the healthcare service or treatment that is the subject of the adverse determination or final adverse determination. (4) (A) Immediately upon making the decision to reverse its adverse determination or final adverse determination, the health insurance organization or issuer shall notify, in writing, the covered person or enrollee, the assigned independent review organization, and the Commissioner of its decision. (B) The independent review organization shall terminate the external review upon receipt of the notice from the health insurance organization or issuer sent pursuant to paragraph (A) of this clause. (h) (1) Except as provided in clause (3) of this subsection, not later than twenty (20) days after being selected to conduct the external review, each clinical reviewer shall provide an opinion to the independent review organization on whether the recommended or requested healthcare service or treatment should be covered. (2) Except for an opinion provided pursuant to clause (3) of this subsection, each clinical reviewer's opinion shall be in writing and include the following information: (A) A description of the covered person or enrollee's medical condition; (B) a description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested healthcare service or treatment is more likely than not to be beneficial to the covered person or enrollee than any available standard healthcare services or treatments and that the adverse risks of the recommended or requested healthcare service or treatment would not be substantially increased over those of available standard healthcare services or treatments; (C) a description and analysis of any medical or scientific evidence considered in reaching the opinion; (D) a description and analysis of any evidence-based standard, taken into account in reaching an opinion, and (E) information on whether the reviewer's rationale for the opinion is based on paragraph (A) or (B) of subsection (i)(5) of this section. (3) (A) For an expedited external review, each clinical reviewer shall provide an opinion orally or in writing to the independent review organization as expeditiously as the covered person or enrollee's medical condition or circumstances requires, but in no event more than five (5) calendar days after being selected to conduct the external review. (B) If the opinion of the clinical reviewer was not in writing, within two (2) days following the date the opinion was provided, the clinical reviewer shall provide written confirmation of the opinion to the independent review organization and include the information required under clause (2) of this subsection. (i) In addition to the documents and information provided pursuant to subsection (a)(2)(F) or subsection (e)(1) of this section, each clinical reviewer, to the extent the information or documents are available and the reviewer considers appropriate, shall consider the following in reaching an opinion: (1) The covered person or enrollee's pertinent medical records; (2) the covered person or enrollee's attending physician or healthcare professional's recommendation; (3) consulting reports from appropriate healthcare professionals and other documents submitted by the health insurance organization or issuer, covered person or enrollee, or his/her treating physician or healthcare professional; (4) the terms of coverage under the covered person or enrollee's health plan, and (5) the applicable alternative, if applicable, of the following: (A) The recommended or requested healthcare service or treatment has been approved by the federal Food and Drug Administration (FDA), if applicable, for the condition of the covered person or enrollee, or (B) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested healthcare service or treatment is more likely than not to be beneficial to the covered person or enrollee than any available standard healthcare service or treatment and that the adverse risks of the recommended or requested healthcare service or treatment would not be substantially increased over those of available standard healthcare services or treatments. (j) (1) (A) Except as provided in paragraph (B) of this clause, not later than twenty (20) days after the date it receives the opinion of each clinical reviewer, the independent review organization, in accordance with clause (2) of this subsection, shall make a decision and provide written notice of the decision to: (i) The covered person or enrollee; (ii) the health insurance organization or issuer, and (iii) the Commissioner. (B) (i) For an expedited external review, not later than forty-eight (48) hours after the date it receives the opinion of each clinical reviewer, the independent review organization shall make a decision and provide notice of the decision orally or in writing to the covered person or enrollee, the health insurance organization or issuer, and the Commissioner. (ii) If notice of the determination was not in writing, not later than two (2) days after the date of providing that notice, the independent review organization shall provide written confirmation of the decision to the covered person or enrollee, the health insurance organization or issuer, and the Commissioner and shall include the information set forth in clause (3) of this subsection. (2) (A) If a majority of the clinical reviewers recommend that the recommended or requested healthcare service or treatment should be covered, the independent review organization shall make a decision to reverse the health insurance organization or issuer's adverse determination or final adverse determination subject of the review. (B) If a majority of the clinical reviewers recommend that the recommended or requested healthcare service or treatment should not be covered, the independent review organization shall make a decision to uphold the health insurance organization or issuer's adverse determination or final adverse determination. (C) (i) If the clinical reviewers are evenly split as to whether the recommended or requested healthcare service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer in order for the independent review organization to make a decision based on the opinions of a majority of the clinical reviewers. (ii) If the need to select an additional clinical reviewer arises in accordance with the preceding item, such additional clinical reviewer shall use the same information to reach an opinion as the clinical reviewers who have already submitted their opinions. (iii) The selection of the additional clinical reviewer shall not extend the time within which the independent review organization is required to make a decision based on the opinions of the clinical reviewers selected. (3) The independent review organization shall include in the notice: (A) A general description of the reason for the request for external review; (B) the written opinion of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested healthcare service or treatment should be covered and the rationale for the reviewer's recommendation; (C) the date the independent review organization was assigned by the Commissioner to conduct the external review; (D) the date the external review was conducted; (E) the date of its decision; (F) the principal reason or reasons for its decision, and (G) the rationale for its decision. (4) If the independent review organization reverses the adverse determination or final adverse determination, the health insurance organization or issuer involved immediately shall approve coverage or payment of the healthcare service or treatment subject of the review. (k) The assignment by the Commissioner of an independent review organization to conduct an external review in accordance with this section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review in question based on the nature of the healthcare service that is the subject of the adverse determination or final adverse determination and other circumstances, including potential conflict of interests. History —Aug. 29, 2011, No. 194, added as § 28.100 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9511/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9511 - Binding nature of external review decision	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9511 - Binding nature of external review decision	(a) An external review decision is binding on the health insurance organization or issuer except to the extent the health insurance organization or issuer has other remedies available under the applicable laws of Puerto Rico. (b) An external review decision is binding on the covered person or enrollee, except to the extent the covered person or enrollee has other remedies available under the applicable laws of Puerto Rico or federal law. (c) A covered person or enrollee may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to this chapter. History —Aug. 29, 2011, No. 194, added as § 28.110 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9512/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9512 - Approval of independent review organizations	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9512 - Approval of independent review organizations	(a) The Commissioner shall approve independent review organizations eligible to be assigned to conduct external reviews under this chapter. (b) In order to be eligible for approval by the Commissioner under this chapter to conduct external reviews, an independent review organization: (1) Except as otherwise provided in this Section, shall be accredited by a recognized private accrediting entity that the Commissioner has determined has independent review organization accreditation standards that are equivalent to or exceed the minimum qualifications for independent review organizations established under § 9513 of this title, and (2) shall submit an application for approval to the Commissioner in accordance with subsection (d) of this section. (c) The Commissioner shall develop an application form for initially approving and for reapproving independent review organizations to conduct external reviews. (d) (1) Any independent review organization wishing to be approved by the Commissioner to conduct external reviews under this chapter shall submit the application form and include with the form all documentation and information necessary for the Commissioner to determine if the independent review organization satisfies the minimum requirements of capacity and competence established under § 9513 of this title. (2) (A) Subject to paragraph (B) of this clause, an independent review organization shall be eligible for approval by the Commissioner only if it is accredited by a recognized private accrediting entity that the Commissioner has determined has independent review organization accreditation standards that are equivalent to or exceed the minimum requirements of capacity and competence established under § 9513 of this title. (B) The Commissioner may approve an independent review organization that is not accredited by a recognized private accrediting entity only if there are no acceptable recognized private accrediting entities providing independent review organization accreditation. (3) The Commissioner may charge a fee or contribution as deemed convenient for independent review organization applications for approval and re-approval. (e) (1) An independent review organization approval shall be effective for two (2) years, unless the Commissioner determines before its expiration that the independent review organization is not satisfying the minimum requirements of capacity and competence established under § 9513 of this title. (2) Whenever the Commissioner determines that an independent review organization no longer satisfies the minimum requirements of capacity and competence established under § 9513 of this title, the Commissioner shall terminate the approval of the independent review organization and remove it from the list of independent review organizations approved to conduct external reviews under this chapter. (f) The Commissioner shall maintain and periodically update a list of approved independent review organizations. (g) The Commissioner may promulgate regulations as necessary to carry out the duties imposed under this section. History —Aug. 29, 2011, No. 194, added as § 28.130 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9513/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9513 - Minimum requirements of capacity and competence for independent review organizations	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9513 - Minimum requirements of capacity and competence for independent review organizations	(a) To be approved by the Commissioner to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process that include, at least: (1) A quality assurance mechanism that: (A) Ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner; (B) ensures the proper selection of qualified and impartial clinical reviewers; the entity must have written policies and procedures so that reviewers may reveal any conflict of interest; (C) ensures the confidentiality of medical records and clinical review criteria, and (D) ensures that any person employed or contracted by the independent review organization adheres to the requirements of this chapter. (2) A toll-free telephone service to receive information related to external reviews. The telephone service shall operate on a 24-hour-day, 7-days-a-week basis and be capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours. (3) Agree to maintain and provide to the Commissioner the information set out in § 9515 of this title. (b) All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other healthcare providers who meet the following minimum qualifications: (1) Be an expert in the treatment of the covered person or enrollee's medical condition; (2) be knowledgeable about the recommended or requested healthcare service or treatment. Such knowledge must have been acquired through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person or enrollee; (3) hold a non-restricted license in a state of the United States or in Puerto Rico and, for physicians, a current certification by a medical specialty board recognized in the United States or Puerto Rico in the area or areas appropriate to the subject of the external review, and (4) have no history of disciplinary actions or sanctions that raise a substantial question as to the clinical reviewer's physical, mental or professional competence or moral character. (c) In addition to the requirements set forth in subsection (a) of this section, an independent review organization may not own or control, be a subsidiary of or in any way be controlled by, or exercise control with a health plan or a professional association of healthcare providers. (d) (1) In addition to the requirements set forth in subsections (a), (b), and (c) of this section, to be approved to conduct an external review of a specified case, neither the independent review organization nor any clinical reviewer assigned may have a material professional or familial interest or financial conflict of interest with any of the following: (A) The health insurance organization or issuer involved; (B) the covered person or enrollee who requested external review; (C) any officer, director or management employee of the health insurance organization or issuer involved; (D) the healthcare provider, the healthcare provider's medical group or independent practice association recommending the healthcare service or treatment subject of the external review; (E) the facility at which the recommended healthcare service or treatment would be provided, or (F) the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person or enrollee. (2) In determining whether an independent review organization or a clinical reviewer has a material professional or familial interest or financial conflict of interest, the Commissioner shall take into consideration situations where the independent review organization or a clinical reviewer may have an apparent professional, familial or financial relationship or connection with a person described in clause (1) of this subsection, but that the characteristics of that relationship or connection are such that they are not a material conflict of interests that impairs them from conducting the external review. (e) (1) An independent review organization that is accredited by an accrediting entity recognized by the Commissioner, whose independent review organization accreditation standards, in the judgment of the Commissioner, are equivalent to or exceed the minimum requirements of capacity and competence established under this section shall be presumed in compliance with this section to be eligible for approval under § 9512 of this title. (2) The Commissioner shall initially and periodically review the independent review organization accreditation standards of accrediting entities to determine whether the entity's standards are, and continue to be, equivalent to or exceed the minimum requirements of capacity and competence established under this section. To comply with the review duty imposed herein, the Commissioner may accept a review conducted by the NAIC of accrediting organizations. (3) Upon request, accrediting entities shall make their independent review organization accreditation standards available to the Commissioner in order for him/her to make the corresponding determinations pursuant to this chapter. (f) An independent review organization shall be unbiased and shall establish and maintain written procedures to ensure that it is unbiased in addition to any other requirement under this chapter. History —Aug. 29, 2011, No. 194, added as § 28.140 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9514/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9514 - Hold harmless for independent review organizations	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9514 - Hold harmless for independent review organizations	No independent review organization, clinical reviewer or an employee, agent or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of their duties under this chapter, unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence or noncompliance with the requirement to disclose any conflict of interests. History —Aug. 29, 2011, No. 194, added as § 28.150 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9515/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9515 - External review reporting requirements	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9515 - External review reporting requirements	(a) (1) Any independent review organization shall maintain written records of all external reviews it conducted during a calendar year and submit a report to the Commissioner, as required under clause (2) of this subsection. Such reports shall be made with respect to each health insurance organization or issuer individually and in the aggregate. (2) Each independent review organization shall submit to the Commissioner at least once a year a report regarding the external reviews it conducted during the preceding calendar year in the format specified by the Commissioner. (3) The report shall include the following information and for each health insurance organization or issuer specifically and in the aggregate: (A) The total number of requests for external review; (B) the number of requests for external review resolved and, of those resolved, the number resolved upholding and the number resolved reversing determinations; (C) the average length of time for resolution; (D) a summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the Commissioner; (E) the number of external reviews that were terminated as a result of reconsideration by the health insurance organization or issuer after the receipt of additional information from the covered person or enrollee, and (F) any other information the Commissioner may request or require. (4) The independent review organization shall retain the written records required under this section for at least six (6) years. (b) (1) Each health insurance organization or issuer shall maintain written records, in the aggregate and for each type of health plan offered, on all requests for external review filed against them. (2) Each health insurance organization or issuer shall submit to the Commissioner, upon request, a report on all requests for external review filed against them in the format specified by the Commissioner. (3) The report shall include in the aggregate and specifically by each type of health plan: (A) The total number of requests for external review. (B) From the total number of requests for external review, the number of requests determined eligible for a full external review. (C) Any other information the Commissioner may request or require. (4) The health insurance organization or issuer shall retain the written records required under this section for at least six (6) years. History —Aug. 29, 2011, No. 194, added as § 28.160 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9516/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9516 - Funding of external review	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9516 - Funding of external review	The health insurance organization or issuer against which a request for a standard external review or an expedited external review is filed shall be required to pay the independent review organization for conducting the external review. The Office of the Insurance Commissioner shall notify health service organizations and issuers the costs of the process or any modification thereof within one hundred twenty (120) days in advance. A covered person or enrollee shall pay not more than twenty-five dollars ($25) for each review. Provided, That the same covered person or enrollee shall not pay more than seventy-five dollars ($75) per policy year. The amount paid by the covered person or enrollee shall be reimbursed to him/her if a decision is made in his/her favor. History —Aug. 29, 2011, No. 194, added as § 28.170 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-126/9517/	PR	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 126 - External Review (§§ 9501 — 9517)›§ 9517 - Disclosure requirements	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9517 - Disclosure requirements	(a) (1) Each health insurance organization or issuer shall include a description of the external review procedures in the policy, certificate, membership booklet, outline of coverage. or other evidence of coverage it provides to covered persons or enrollees. (2) The disclosure of external review procedures required by clause (1) of this subsection shall be in a format prescribed by the Commissioner. (b) The description of external review procedures shall include a statement that informs the covered person or enrollee of his/her right to file a request for an external review of an adverse determination or final adverse determination with the Commissioner. The statement may explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, healthcare setting, level of care, or effectiveness of service or rescission of coverage. The statement shall include the telephone number and address of the Commissioner. (c) In addition to the provisions of subsection (b) of this Section, the statement shall inform the covered person or enrollee that, when filing a request for an external review, he/she will be required to authorize the release of any medical information that may be required or necessary to be reviewed for the purpose of reaching a decision on the external review. History —Aug. 29, 2011, No. 194, added as § 28.180 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-150/9981/	PR	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 150 - Off-label Use (§§ 9981 — 9984)›§ 9981 - Purpose	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9981 - Purpose	The purpose of this chapter is to establish standards for the payment or reimbursement of costs associated with prescription drugs that, even though they have been approved by the U. S. Food and Drug Administration (FDA), are used for indications other than those stated in the labeling approved by the FDA (this use is hereinafter referred to as “off-label use”). Denial of payment or reimbursement for off-label use can interrupt or effectively deny access to necessary and appropriate treatment for covered persons or enrollees. History —Aug. 29, 2011, No. 194, added as § 52.010 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-150/9982/	PR	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 150 - Off-label Use (§§ 9981 — 9984)›§ 9982 - Applicability and scope	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9982 - Applicability and scope	This chapter shall apply to all health plans that are issued, amended, delivered or renewed on or after the effective date of this chapter and provide coverage for drugs. It also shall apply to all persons making determinations regarding payment of reimbursement for prescription drugs under these health plans. History —Aug. 29, 2011, No. 194, added as § 52.020 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-150/9983/	PR	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 150 - Off-label Use (§§ 9981 — 9984)›§ 9983 - Definitions	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9983 - Definitions	(a) Standard reference compendia.— Means: (1) The American Hospital Formulary Service-Drug Information; (2) The American Medical Association Drug Evaluation; or (3) The United States Pharmacopoeia-Drug Information. (b) FDA.— Means the United States Food and Drug Administration. (c) Peer-reviewed medical literature.— Means a published scientific study in a journal or other publication in which original manuscripts have been published only after having been critically reviewed by unbiased independent experts, and that has been determined by the International Committee of Medical Journal Editors to have met the Uniform Requirements for Manuscripts submitted to biomedical journals. Peer-reviewed medical literature does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or a health insurance organization or issuer. (d) Drug or Drugs.— Means any substance prescribed by a licensed healthcare provider that is intended for use in the diagnosis, mitigation, treatment or prevention of disease that is taken (by mouth; injected into a muscle, the skin, a blood vessel or cavity of the body; applied to the skin; or otherwise assimilated by the body). The term includes only those substances that are approved by the FDA for at least one indication. History —Aug. 29, 2011, No. 194, added as § 52.030 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-150/9984/	PR	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 150 - Off-label Use (§§ 9981 — 9984)›§ 9984 - Standards of coverage	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 150 - Off-label Use (§§ 9981 — 9984) › § 9984 - Standards of coverage	(a) A health plan that provides coverage for drugs shall provide for the dispensation of any drug covered, regardless of the disorder, injury, illness, condition, or disease for which they were prescribed, provided, that: (1) The drug has been approved by the FDA for at least one indication, and (2) the drug is recognized for treatment of the disorder, injury, illness, condition, or disease in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature. (b) Coverage of a drug pursuant to this section shall also include medically necessary services associated with the administration of the drug. (c) This section shall not be construed to require a health insurance organization or issuer to provide coverage for a drug when the FDA has determined its use to be contra-indicated for treatment of the current indication. (d) The following drugs or services shall not be subject to coverage under subsection (a) of this section: (1) Drugs that are used in research trials sponsored by their manufacturers or a government entity, or (2) drugs or services furnished in a research trial, if the sponsor of the research trial furnishes the drugs or services without charge to any participant in the research trial. History —Aug. 29, 2011, No. 194, added as § 52.040 on Aug. 23, 2012, No. 203, § 8, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-152/10021/	PR	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 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026)›§ 10021 - Title	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10021 - Title	This chapter shall be known and may be cited as the chapter on Coverage for Newborn and Newly Adopted Children and Children Placed for Adoption. History —Aug. 29, 2011, No. 194, § 54.010, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-152/10022/	PR	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 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026)›§ 10022 - Purpose	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10022 - Purpose	The purpose of this chapter is to provide for uniformity of coverage requirements for newborn and newly adopted children and children placed for adoption under both group and individual health plans. History —Aug. 29, 2011, No. 194, § 54.020, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-152/10023/	PR	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 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026)›§ 10023 - Definitions	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10023 - Definitions	For purposes of this chapter: (a) Health plan.— Means a policy, contract, certificate, or agreement offered or issued by a health insurance organization or issuer to provide, deliver, arrange for healthcare service or pay for or reimburse the costs thereof. History —Aug. 29, 2011, No. 194, § 54.030, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-152/10024/	PR	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 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026)›§ 10024 - Applicability	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10024 - Applicability	(a) Except as provided in subsection (b) of this section, this chapter shall apply to health plans that provide coverage for a dependent of a covered person or enrollee. (b) The provisions of this chapter shall not apply to a group or individual health plan that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity or other fixed indemnity coverage, vision care or any other supplemental benefit or a Medicare supplement policy, coverage under a plan through Medicare, Medicaid or the federal employees health benefits program, any coverage issued as supplemental to liability insurance, workers' compensation or similar insurance, automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault. History —Aug. 29, 2011, No. 194, § 54.040, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-152/10025/	PR	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 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026)›§ 10025 - Coverage requirements	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10025 - Coverage requirements	(a) Each health plan subject to this chapter shall provide coverage to: (1) A newborn child of a covered person or enrollee from the moment of birth, or (2) a newly adopted child of a covered person or enrollee from the earlier of: (A) The date of placement in the home of the covered person or enrollee for the purpose of adoption and continues in the same manner as other dependents of the covered person or enrollee unless the placement is disrupted prior to legal adoption and the child is removed from placement; (B) the date of entry of an order granting the covered person or enrollee custody of the child for purposes of adoption, or (C) the effective date of adoption. (b) The coverage for newborn and newly adopted children and children placed for adoption shall meet the following requirements: (1) Include coverage of injury or sickness healthcare services including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, and (2) is not subject to any preexisting condition exclusion. History —Aug. 29, 2011, No. 194, § 54.050, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-152/10026/	PR	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 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026)›§ 10026 - Notification requirements	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 152 - Coverage for Newborn and Recently Adopted Children and Children Placed for Adoption (§§ 10021 — 10026) › § 10026 - Notification requirements	(a) For a newborn child, the health insurance organization or issuer shall be required to provide covered persons or enrollees with reasonable notice of the following: (1) If payment of a specific premium or subscription fee is required to provide coverage for a newborn child, as provided in this chapter, the health plan may require the covered person or enrollee to notify the health insurance organization or issuer of the birth of the child and furnish payment of the required premium or fees within thirty (30) days after the date of birth. (2) If notice and the payment described above are not provided, the health insurance organization or issuer may refuse to continue coverage for the child under the health plan beyond the thirty (30)-day period. However, if within four (4) months after the birth of the child the covered person or enrollee makes all past-due payments, coverage shall be restored. (3) If payment of a specific premium or subscription fee is not required to provide coverage for a newborn child, the health insurance organization or issuer may request notification of the birth of the child, but shall not deny or refuse to continue coverage if the covered person or enrollee does not furnish the notice. (b) For a newly adopted child or child placed for adoption, the health insurance organization or issuer shall be required to provide covered persons or enrollees with reasonable notice of the following: (1) If payment of a specific premium or subscription fee is required to provide coverage for a newly adopted child or child placed for adoption, the health plan may require the covered person or enrollee to notify the health insurance organization or issuer of the adoption or placement for adoption and furnish payment of the required premium or fees within thirty (30) days after coverage is required to begin under § 10025(a)(2) of this title. (2) If the covered person fails to provide the notice or make the payment described in the preceding paragraph within the thirty (30)-day period, the health insurance organization or issuer shall treat the adopted child or child placed for adoption no less favorably than it treats other dependents, other than newborn children, who seek coverage at a time other than when the dependent was first eligible to apply for coverage. History —Aug. 29, 2011, No. 194, § 54.060, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10251/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10251 - Title	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10251 - Title	This chapter shall be known and may be cited as the chapter on Long-term Care Insurance. History —Aug. 29, 2011, No. 194, § 66.010, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10252/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10252 - Scope	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10252 - Scope	The requirements of this chapter shall apply to policies delivered or issued for delivery in Puerto Rico on or after the effective date thereof. This chapter is not intended to supersede the obligations of entities subject to this chapter to comply with the provisions of other applicable insurance laws insofar as they do not conflict with this chapter, except that laws and regulations designed and intended to apply to Medicare supplement insurance policies shall not be applied to long-term care insurance. History —Aug. 29, 2011, No. 194, § 66.020, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10253/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10253 - Purpose	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10253 - Purpose	The purpose of this chapter is to promote the public interest, and the availability of long-term care insurance policies, to protect applicants for long-term care insurance, as defined, from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to facilitate flexibility and innovation in the development of long-term care insurance coverage. History —Aug. 29, 2011, No. 194, § 66.030, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10254/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10254 - Definitions	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10254 - Definitions	For purposes of this chapter: (a) Certificate.— Means any certificate issued under a group long-term care insurance policy, policy has been delivered or issued for delivery in Puerto Rico. (b) Qualified long-term care insurance contract or federally tax-qualified long-term care insurance contract.— Means an individual or group insurance contract that meets the requirements of the U.S. Internal Revenue Code of 1986, as amended, as follows: (1) The only insurance protection provided under the contract is coverage of qualified long-term care services established in accordance with federal income tax laws. A contract shall not fail to satisfy the requirements of this paragraph by reason of payments being made on a periodic basis (per diem or other period) without regard to the expenses incurred during such period; (2) the contract does not provide for the payment or reimbursement of expenses incurred for services or items that are reimbursable under Title XVIII of the Social Security Act, as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount. The requirements of this clause do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor. A contract shall not fail to satisfy the requirements of this clause by reason of payments being made on a periodic basis (per diem or other period)without regard to the expenses incurred during such period; (3) the contract is guaranteed renewable, as defined in the U.S. Internal Revenue Code of 1986, as amended; (4) the contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in Section 66.040B(1)(e) of this Chapter [sic]; (5) all refunds of premiums, and all policyholder dividends or similar amounts, under the contract shall be applied as a reduction in future premiums or to increase future benefits, except that a refund on the event of death of the enrollee or a complete surrender or cancellation of the contract cannot exceed the aggregate premiums paid under the contract, and (6) the contract meets the consumer protection provisions set forth in the U.S. Internal Revenue Code of 1986, as amended. “Qualified Long-term Care Insurance Contract” or “Federally Tax-qualified Long-term Care Insurance Contract” also means the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of the U.S. Internal Revenue Code of 1986, as amended. (c) Policy.— Means any policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery in Puerto Rico by an issuer authorized to market disability insurance in Puerto Rico. (d) Long-term care insurance.— Means: (1) Any insurance policy or rider advertised, marketed, offered or designed to provide coverage for not less than twelve (12) consecutive months on an expense incurred, indemnity, prepaid or other basis; for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services, provided in a setting other than an acute care unit of a hospital. (2) The term includes group and individual annuities and life insurance policies or riders that provide directly or supplement long-term care insurance. The term also includes a policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. The term shall also include federally tax-qualified long-term care insurance contracts. (3) Long-term care insurance may be issued by issuers authorized to issue disability insurance. (4) Long-term care insurance shall not include any insurance policy that is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset-protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage. (5) With regard to life insurance, this term shall not include life insurance policies that accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention or permanent institutional confinement, and that provide the option of a lump-sum payment for those benefits and where neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. Notwithstanding any other provision of this chapter, any product advertised, marketed or offered as long-term care insurance shall be subject to the provisions of this chapter. (e) Group long-term care insurance.— Means a long-term care insurance policy that is delivered or issued for delivery in Puerto Rico and issued to: (1) One (1) or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof, of the labor organizations, or (2) any professional, trade or occupational association for its members or former or retired members, or combination thereof, if the association: (A) Is composed of individuals all of whom are or were actively engaged in the same profession, trade or occupation, and (B) has been maintained in good faith for purposes other than obtaining insurance; or (3) An association or a trust or the trustees of a fund established, created or maintained for the benefit of members of one or more associations. Prior to advertising, marketing, or offering the policy in Puerto Rico, the association or the issuer of the association, shall file evidence with the Commissioner, since the beginning, that the association has been organized and maintained in good faith for purposes other than obtaining insurance; has been in active existence for at least one (1) year; and has a constitution and bylaws that provide that: (A) The association holds regular meetings not less than annually to further purposes of the members; (B) except for cooperative banks, the association collects dues or solicit contributions from members, and (C) the members have voting privileges and representation on the governing board and committees. Thirty (30) days after the filing the association will be deemed to satisfy the organizational requirements, unless the Commissioner determines otherwise. (4) To qualify as a group long-term care insurance, the issuer shall ensure that the minimum requirements regarding the number of covered persons or enrollees set forth in §§ 1401–1411 of this title are met. (f) Applicant.— Means: (1) In the case of an individual long-term care insurance policy, the person who seeks to obtain insurance. (2) In the case of a group long-term care insurance policy, the proposed certificate holder. History —Aug. 29, 2011, No. 194, § 66.040, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10255/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10255 - Extraterritorial jurisdiction-Group long-term care insurance	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10255 - Extraterritorial jurisdiction-Group long-term care insurance	No group long-term care insurance coverage may be offered to a resident of Puerto Rico under a group policy issued in another state to a group described in § 10254(e) of this title, unless the Government of Puerto Rico, or the government of another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in Puerto Rico, has made a determination that such requirements have been met. History —Aug. 29, 2011, No. 194, § 66.050, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10256/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10256 - Disclosure and performance standards for long-term care insurance	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10256 - Disclosure and performance standards for long-term care insurance	(a) The Commissioner may adopt regulations that include standards for full and fair disclosure setting forth the manner, content and required disclosures for the sale of long-term care insurance policies, terms of renewability, initial and subsequent conditions of eligibility, non-duplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, continuation or conversion, waiting periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, recurrent conditions and definitions of terms. (b) No long-term care insurance policy may: (1) Be cancelled, non renewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the enrollee or certificate holder; or (2) contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the enrollee or group policyholder, or (3) provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care. (c) Preexisting condition.— (1) No long-term care insurance policy or certificate shall use a definition of “preexisting condition” that is more restrictive than the following: “Preexisting condition means a condition for which medical advice or treatment was recommended by, or received from a provider of healthcare services, within six (6) months preceding the effective date of coverage of a covered person.” (2) No long-term care insurance policy or certificate may exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within six (6) months following the effective date of coverage of a covered person. (3) The definition of “preexisting condition” does not prohibit an issuer from using an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, from underwriting in accordance with that issuer’s established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in clause (2) of this subsection expires. No long-term care insurance policy or certificate may exclude or use waivers or riders of any kind to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in clause (2) of this subsection. (d) Prior hospitalization/institutionalization.— (1) No long-term care insurance policy may be delivered or issued for delivery in Puerto Rico if the policy: (A) Conditions eligibility for any benefits on a prior hospitalization requirement; (B) conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care, or (C) conditions eligibility for any benefits other than waiver of premium, post-confinement, post-acute care or recuperative benefits on a prior institutionalization requirement. (2) (A) A long-term care insurance policy containing post-confinement, post-acute care or recuperative benefits shall clearly label in a separate paragraph of the policy or certificate entitled “Limitations or conditions on eligibility for benefits” such limitations or conditions, including any required number of days of confinement. (B) A long-term care insurance policy or rider that conditions eligibility of non-institutional benefits on the prior receipt of institutional care shall not require a prior institutional stay of more than thirty (30) days. (3) No long-term care insurance policy or rider that provides benefits only following institutionalization shall condition such benefits upon admission to a facility for the same or related conditions within a period of less than thirty (30) days after discharge from the institution. (e) The Commissioner may adopt regulations establishing loss ratio standards for long-term care insurance policies. (f) Right to return.— Long-term care insurance applicants shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Long-term care insurance policies and certificates shall have a notice prominently printed on the first page or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within thirty (30) days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason. This subsection shall also apply to denials of applications. Any refund must be made within thirty (30) days of the return or denial. (g) Outline of coverage.— (1) An outline of coverage shall be delivered to a prospective applicant or long-term care insurance at the time of initial solicitation. The outline shall be provided through means that prominently direct the attention of the recipient to the document and its purpose. (A) The Commissioner shall prescribe a standard format, including style, arrangement and overall appearance, and the content of an outline of coverage. (B) In the case of producer solicitations, a producer shall deliver the outline of coverage prior to the presentation of an application or enrollment form. (2) The outline of coverage shall include: (A) A description of the principal benefits and coverage provided in the policy; (B) a statement of the principal exclusions, reductions and limitations contained in the policy; (C) a statement of the terms under which the policy or certificate, or both, may be continued in force or discontinued, including any reservation in the policy of a right to change premium. Continuation or conversion provisions of group coverage shall be specifically described; (D) a statement that the outline of coverage is a summary only, not a contract of insurance, and that the policy or group master policy contains governing contractual provisions; (E) a description of the terms under which the policy or certificate may be returned and premium refunded; (F) a brief description of the relationship of cost of care and benefits, and (G) a statement that discloses to the policyholder or certificate holder whether the policy is intended to be a federally tax-qualified long-term care insurance contract. (h) A certificate issued pursuant to a group long-term care insurance policy that policy is delivered or issued for delivery in Puerto Rico shall include: (1) A description of the principal benefits and coverage provided in the policy; (2) a statement of the principal exclusions, reductions and limitations contained in the policy, and (3) a statement that the group master policy determines governing contractual provisions. (i) If an application for a long-term care insurance contract is approved, the issuer shall deliver the contract or certificate of insurance to the applicant not later than thirty (30) days after the date of approval. (j) At the time of policy delivery, a policy summary shall be delivered for an individual life insurance policy that provides long-term care benefits within the policy or by rider. In addition to meeting all applicable requirements, the summary shall also include: (1) An explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits. (2) An illustration of the amount of benefits, the length of benefit, and the guaranteed lifetime benefits if any, for each covered person or enrollee. (3) Any exclusions, reductions, and limitations on benefits of long-term care. (4) A statement that any long-term care inflation protection option is not available under this policy. (5) If applicable to the policy type, the summary shall also include: (A) A disclosure of the effects of exercising other rights under the policy; (B) a disclosure of guarantees related to long-term care costs of insurance charges, and (C) current and projected maximum lifetime benefits. (k) Any time a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report shall be provided to the policyholder or certificate holder. The report shall include: (1) Any long-term care benefits paid out during the month; (2) an explanation of any changes in the policy, e.g. death benefits or policy cash values, due to long-term care benefits being paid out, and (3) the amount of long-term care benefits existing or remaining. (l) If a claim under a long-term care insurance contract is denied, the issuer, or a representative thereof, within sixty (60) days of the date of a written request by the policyholder or certificate holder shall: (1) Provide a written explanation of the reasons for the denial, and (2) make available all information directly related to the denial. (m) Any policy or rider advertised, marketed or offered as long-term care or nursing home insurance shall comply with the provisions of this chapter. History —Aug. 29, 2011, No. 194, § 66.060, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10257/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10257 - Incontestability period	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10257 - Incontestability period	(a) For a policy or certificate that has been in force for less than six (6) months, an issuer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acceptance for coverage or to the risk assumed by the issuer. (b) For a policy or certificate that has been in force for at least six (6) months but less than two (2) years, an issuer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and which pertains to the condition for which benefits are sought. (c) After a policy or certificate has been in force for two (2) years, it is not contestable upon the grounds of misrepresentation alone; such policy or certificate may be contested only upon a showing that the enrollee knowingly and intentionally misrepresented relevant facts relating to his/her health status. (d) Long-term care insurance policies or certificates may be field issued by third-party administrators if the compensation to the producer or third party administrator is not based on the number of policies or certificates issued. For purposes of this section, “field issued” means a policy or certificate issued by a producer or a third-party administrator pursuant to the underwriting authority granted to the producer or third-party administrator by an issuer and using the issuer’s underwriting guidelines. (e) If an issuer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer in the event that the policy or certificate is rescinded. (f) In the event of the death of the enrollee, this section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In this situation, the remaining death benefits under these policies shall be governed by the provisions of law applicable to life insurance. In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care. History —Aug. 29, 2011, No. 194, § 66.070, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10258/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10258 - Nonforfeiture benefits	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10258 - Nonforfeiture benefits	(a) Except as provided in subsection (b) of this section, a long-term care insurance policy may not be delivered or issued for delivery in Puerto Rico unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture benefit. The offer of a nonforfeiture benefit may be in the form of a rider that is attached to the policy. In the event the policyholder or certificate holder declines the nonforfeiture benefit, the issuer shall provide a contingent benefit upon lapse that shall be available for a specified period of time following a substantial increase in premium rates. (b) When a group long-term care insurance policy is issued, the offer required in subsection (a) of this section shall be made to the group policyholder. (c) The Commissioner shall promulgate regulations specifying the type or types of nonforfeiture benefits to be offered as part of long-term care insurance policies and certificates, the standards for nonforfeiture benefits, and the rules regarding contingent benefit upon lapse, including a determination of the specified period of time during which a contingent benefit upon lapse will be available and the substantial premium rate increase that triggers a contingent benefit upon lapse as described in subsection (a) of this section. History —Aug. 29, 2011, No. 194, § 66.080, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10259/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10259 - Producer training requirements	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10259 - Producer training requirements	(a) The following requirements related to the sale, soliciting or negotiating long-term care insurance shall be met: (1) An individual may not sell, solicit or negotiate long-term care insurance unless the individual has an insurance producer license which authorizes him/her to underwrite disability insurance and has completed the required training course. The training shall meet the requirements set forth in subsection (b) of this section. (2) An individual already licensed and selling, soliciting or negotiating long-term care insurance on the effective date of this chapter may not continue to sell, solicit or negotiate long-term care insurance unless the individual has completed the required training course as set forth in subsection (b) of this section, within one (1) year from the effective date of this chapter. (3) In addition to the training course required in clauses (1) and (2) of this subsection, an individual who sells, solicits or negotiates long-term care insurance shall complete ongoing training as set forth in subsection (b) of this section. (4) The training requirements of subsection (b) of this section may be approved as continuing education courses under Rule 52 of the Insurance Code of Puerto Rico Regulations. (b) The training required by this section shall be not less than eight (8) hours and the ongoing training required by this section shall be not less than four (4) hours every twenty-four (24) months. The training shall consist of topics related to long-term care insurance, long-term care services and, if applicable, qualified state long-term care insurance partnership programs, including, but not limited to: (1) Commonwealth and federal regulations and requirements and the relationship between qualified state long-term care insurance partnership programs and other public and private coverage of long-term care services, including Medicaid; (2) available long-term services and providers; (3) changes or improvements in long-term care services or providers; (4) alternatives to the purchase of private long-term care insurance; (5) the effect of inflation on benefits and the importance of inflation protection, and (6) consumer suitability standards and guidelines. The training required by this section shall not include training that is issuer or company product specific or that includes any sales or marketing information, materials, or training, other than those required by Commonwealth or federal law. (c) Issuers subject to this chapter shall obtain verification that a producer receives training required by this section before a producer is permitted to sell, solicit or negotiate the issuer’s long-term care insurance products, maintain records subject to the Commonwealth’s record retention requirements, and make that verification available to the Commissioner upon request. Issuers subject to this chapter shall maintain records with respect to the training of its producers concerning the distribution of its partnership policies, if applicable, that will allow the Commissioner to provide assurance to the state Medicaid agency that producers have received the training described in this section and that producers have demonstrated an understanding of the partnership policies, if applicable, and their relationship to public and private coverage of long-term care, including Medicaid, in Puerto Rico. These records shall be maintained in accordance with the Commonwealth’s retention requirements and shall be made available to the Commissioner upon request. (d) The satisfaction of these training requirements in any state shall be deemed to satisfy the training requirements in Puerto Rico. History —Aug. 29, 2011, No. 194, § 66.090, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10260/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10260 - Rulemaking authority	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10260 - Rulemaking authority	The Commissioner shall issue reasonable regulations to promote premium adequacy and to protect the policyholder or certificate holder in the event of substantial rate increases, and to establish minimum standards for producer education, marketing practices, producer compensation, producer testing, penalties and reporting practices for long-term care insurance. The Commissioner shall issue reasonable regulations to promote premium adequacy and to protect the policyholder or certificate holder in the event of substantial rate increases, and to establish minimum standards for producer education, marketing practices, producer compensation, producer testing, penalties and reporting practices for long-term care insurance [sic]. History —Aug. 29, 2011, No. 194, § 66.100, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-164/10261/	PR	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 164 - Long-term Care Insurance (§§ 10251 — 10261)›§ 10261 - Penalties	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 164 - Long-term Care Insurance (§§ 10251 — 10261) › § 10261 - Penalties	In addition to any other penalties provided by the laws of Puerto Rico including the Insurance Code of Puerto Rico, any issuer and any producer found to have violated any requirement of Puerto Rico related to the regulation of long-term care insurance or the marketing of such insurance shall be subject to a fine which shall be the greater of the following amounts: up to three (3) times the amount of any commissions paid for each policy involved in the violation, or up to $10,000. History —Aug. 29, 2011, No. 194, § 66.130, eff. 180 days after Aug. 29, 2011.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-170/10371/	PR	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 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377)›§ 10371 - Purpose	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377) › § 10371 - Purpose	The purpose of this chapter is to prohibit unfair discrimination by health insurance organizations or issuers and insurance professionals against victims of abuse. History —Aug. 29, 2011, No. 194, added as § 72.010 on Aug. 23, 2012, No. 203, § 9, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-170/10372/	PR	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 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377)›§ 10372 - Scope	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377) › § 10372 - Scope	This chapter shall apply to all health insurance organizations or issuers and insurance professionals involved in issuing or renewing in Puerto Rico a health plan policy or certificate. History —Aug. 29, 2011, No. 194, added as § 72.020 on Aug. 23, 2012, No. 203, § 9, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-170/10373/	PR	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 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377)›§ 10373 - Definitions	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377) › § 10373 - Definitions	(a) Abuse-related medical condition.— Means a medical condition sustained by a victim of abuse which arises in whole or in part out of an act or pattern of abuse. (b) Confidential abuse information.— Means information about acts of abuse against a person or abuse status of such person; information about a person's medical condition that the issuer knows or has reason to know is abuse-related, the address and telephone number (home and work) of a victim of abuse, or the status of a current or potential covered person or enrollee as a family member or employer of a victim of abuse. (c) Abuse.— Means the occurrence of one (1) or more of the following acts by a current or former family member, household member, intimate partner or caretaker: (1) Attempting to cause or intentionally or recklessly causing another person bodily injury, physical harm, severe emotional distress, psychological trauma, rape, sexual assault, or involuntary sexual intercourse; (2) knowingly engaging in an unwanted pursuit behavior towards the victim, including following the person without proper authority, under circumstances that place the victim in reasonable fear of harm to his/her bodily integrity; (3) subjecting another person to false imprisonment, or (4) cause knowingly or recklessly damage to property so as to intimidate or control the behavior of the victim. (d) Health plan or plan.— Means a policy, contract, certificate or agreement offered by a health insurance organization or issuer or insurance professional to provide, deliver, arrange for, pay for or reimburse any of the costs of healthcare services. For purposes of this chapter, health plan includes accident only, credit health, dental, vision, Medicare supplement or long-term care insurance, coverage issued as a supplement to liability insurance, short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis. “Health plan” does not include workers' compensation or similar insurance. (e) Insurance professional.— Means a producer, broker, or adjuster as such terms are defined in §§ 949–953i of this title, as well as third-party administrators, as such terms are defined in Chapter 38 of this Code[sic]. (f) Abuse status.— Means the fact or perception that a person is or has been a victim of abuse, irrespective of whether the person has sustained abuse- related medical conditions. (g) Victim of abuse.— Means a person against whom an act of abuse has been directed; who has current or prior injuries, illnesses, or disorders that resulted from abuse; or who seeks, may have sought, or had reason to seek medical or psychological treatment for abuse; or protection, court-ordered protection, or shelter from abuse. History —Aug. 29, 2011, No. 194, added as § 72.030 on Aug. 23, 2012, No. 203, § 9, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-170/10374/	PR	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 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377)›§ 10374 - Unfairly discriminatory acts relating to health plans	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377) › § 10374 - Unfairly discriminatory acts relating to health plans	(a) It is unfairly discriminatory to: (1) Deny, refuse to issue, renew or reissue, cancel or otherwise terminate a health plan, or restrict a health plan coverage or add a premium differential or surcharge to any health plan on the basis of the covered person or enrollee's abuse status, or (2) exclude, limit coverage, or deny a claim on the basis of the covered person or enrollee's abuse status; (b) When the health insurance organization or issuer or insurance professional has information in its possession that clearly indicates that the current of potential covered person or enrollee is a victim of abuse, the disclosure or transfer of the confidential abuse information, as defined in this chapter, by a health insurance organization or issuer or insurance professional for any purpose or to any person is unfairly discriminatory, except: (1) To the victim of abuse or an individual specifically designated in writing by the victim of abuse; (2) to a healthcare provider for the direct provision of healthcare services; (3) to a physician identified and designated by the victim of abuse; (4) when ordered by the Commissioner or a court of competent jurisdiction or otherwise required by law, or (5) when necessary for a valid business purpose to transfer information that includes confidential abuse information that cannot reasonably be segregated without undue hardship. Confidential abuse information may be disclosed only if the recipient has executed a written agreement to be bound by the prohibitions of this chapter and to be subject to the enforcement of this chapter by the courts of Puerto Rico. Disclosure of confidential abuse information for valid business purposes is hereby authorized under this section only to the following persons: (A) A reinsurer that shall indemnify all or any part of a policy covering a victim of abuse, provided that the reinsurer cannot underwrite or satisfy its obligations under the reinsurance agreement without that disclosure; (B) a party to a proposed or consummated sale, transfer, merger or consolidation of all or part of the business of the health insurance organization or issuer or insurance professional; (C) medical or claims personnel contracting with the health insurance organization or issuer or insurance professional, only when such disclosure is necessary to process an application or perform its duties under the policy, or (D) with respect to the address and telephone number of the victim of abuse, to entities with whom the health insurance organization or issuer or insurance professional transacts business when the business cannot be transacted without the address and telephone number. (6) to an attorney who needs the information to represent the health insurance organization or issuer or insurance professional effectively, provided the health insurance organization or issuer or insurance professional notifies the attorney of its obligations under this chapter and requests that the attorney exercise due diligence to protect the confidential abuse information; (7) to the policy owner or assignee, in the course of delivery of the policy, if the policy contains information about abuse status, or (8) to any other entities deemed appropriate by the Commissioner. (c) It is unfairly discriminatory to request information relating to acts of abuse or a current or potential covered person or enrollee's abuse status, or make use of that information, however obtained, except for the limited purposes of complying with legal obligations or verifying a person's claim to be a victim of abuse. (d) It is unfairly discriminatory to terminate group coverage for a victim of abuse because coverage was originally issued in the name of the abuser and the abuser has divorced, separated from, or lost custody of the victim of abuse, or the abuser's coverage has terminated voluntarily or involuntarily. Nothing in this subsection prohibits the health insurance organization or issuer or insurance professional from requiring the victim of abuse to pay the full premium for coverage under the health plan or from requiring as a condition of coverage that the victim of abuse reside or work within the health plan service area, if the requirements are applied to all existing or potential covered persons or enrollees. The health insurance organization or issuer may terminate group coverage after the continuation coverage required by this subsection has been in force for eighteen (18) months, if it offers conversion to an equivalent individual plan. The continuation coverage required herein shall be satisfied by coverage required under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), and shall not be in addition to coverage provided under COBRA. (e) The provisions of subsection (b) of this section shall not preclude a victim of abuse from obtaining his/her insurance records. (f) The provisions of subsection (d) of this section shall not prohibit a health insurance organization or issuer or insurance professional from asking about a medical condition or from using medical information to underwrite or to carry out its duties under the policy, even if the medical information is related to a medical condition that the issuer or insurance professional knows or has reason to know is abuse-related, to the extent otherwise permitted under this chapter and other applicable law. History —Aug. 29, 2011, No. 194, added as § 72.040 on Aug. 23, 2012, No. 203, § 9, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-170/10375/	PR	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 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377)›§ 10375 - Justification of adverse insurance decisions	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377) › § 10375 - Justification of adverse insurance decisions	A health insurance organization or issuer or insurance professional that takes an action that adversely affects a current or potential covered person or enrollee on the basis of a medical condition that the issuer or insurance professional knows or has reason to know is abuse-related shall explain the reason for its action to the covered person or enrollee in writing and shall be able to demonstrate that its action, and any applicable plan provision: (a) Does not have the purpose of treating the victim of abuse as a medical condition or underwriting criterion; (b) is not based upon any actual or perceived correlation between a medical condition and abuse; (c) is otherwise permissible by law and applies in the same manner and to the same extent to all current or potential covered persons or enrollees with a similar medical condition without regard to whether the condition or claim is abuse-related, and (d) except for claim actions, is based on a determination, made in conformance with sound actuarial principles and supported by reasonable statistical evidence, that there is a correlation between the medical condition and a material increase in insurance risk. History —Aug. 29, 2011, No. 194, added as § 72.050 on Aug. 23, 2012, No. 203, § 9, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-170/10376/	PR	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 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377)›§ 10376 - Insurance protocols for victims of abuse	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377) › § 10376 - Insurance protocols for victims of abuse	Health insurance organizations or issuers shall develop and adhere to written policies specifying procedures to be followed by employees and by insurance professionals they contract with, for the purpose of protecting the safety and privacy of a victim of abuse and shall otherwise implement the provisions of this chapter when taking an application, investigating a claim, pursuing subrogation or taking any other action relating to a policy or claim involving a victim of abuse. Health insurance organizations or issuers shall distribute their written policies to employees and insurance professionals. History —Aug. 29, 2011, No. 194, added as § 72.060 on Aug. 23, 2012, No. 203, § 9, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-170/10377/	PR	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 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377)›§ 10377 - Enforcement	2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 170 - Unfair Discrimination against Victims of Abuse (§§ 10371 — 10377) › § 10377 - Enforcement	The Commissioner shall conduct a reasonable investigation based on a complaint received and issue a prompt determination as to whether a violation of this chapter may have occurred. If the Commissioner finds from the investigation that a violation of this chapter may have occurred, the Commissioner shall promptly begin an administrative adjudicatory proceeding. The Commissioner may address a violation through means appropriate to the nature and extent of the violation, which may include suspension or revocation of certificates of authority or licenses, imposition of civil penalties, issuance of cease and desist orders, injunctive relief, a requirement for restitution, referral to prosecutorial authorities or any combination thereof. The powers and duties set forth in this section are in addition to all other authority of the Commissioner. History —Aug. 29, 2011, No. 194, added as § 72.070 on Aug. 23, 2012, No. 203, § 9, eff. 90 days after Aug. 23, 2012.
https://law.justia.com/codes/puerto-rico/title-twenty-seven/part-i/chapter-15/261/	PR	Justia›US Law›US Codes and Statutes›Laws of Puerto Rico›2023 Laws of Puerto Rico›TITLE TWENTY-SEVEN - Public Service (§§ 1 — 2641)›PART I - Regulation of Companies Rendering Public Service (§§ 1 — 262g)›Chapter 15 - Revision and Modification of Rates (§§ 261 — 261e)›§ 261 - Title and purpose	2023 Laws of Puerto Rico › TITLE TWENTY-SEVEN - Public Service (§§ 1 — 2641) › PART I - Regulation of Companies Rendering Public Service (§§ 1 — 262g) › Chapter 15 - Revision and Modification of Rates (§§ 261 — 261e) › § 261 - Title and purpose	This chapter shall be known as the “Uniform Rate Revision and Modification Act” and shall have the purpose of guaranteeing to the subscribers or users of public services adequate and uniform administrative procedures for the revision and modification of the rates fixed and charged for basic and essential services rendered by public corporations and other similar government instrumentalities. History —May 31, 1985, No. 21, p. 67, § 1.