2023 Laws of Puerto Rico › TITLE TWENTY-FOUR - Health and Sanitation (§§ 1 — 15010) › PART IX - Health Insurance (§§ 7001 — 7075) › Chapter 301 - Health Insurance Administration (§§ 7001 — 7054) › Subchapter III - Health Insurance Administration (§§ 7003 — 7014) › § 7004 - Purposes, functions and powers

The Administration shall be the government body in charge of implementing the provisions of this chapter. To such purposes, it shall have the following powers and functions which shall rest on its Board of Directors:
(a) To implement medical-hospital service plans based on health insurance.
(b) To negotiate and contract medical hospital insurance coverage with public and private insurers and health services organizations, as defined and established in §§ 7025–7036 of this title.
(c) Directly negotiate and contract with health service purveyors, those health services that the Administration deems convenient, considering the capacity and structure thereof.
(d) Organize alliances and conglomerates of beneficiaries with the purpose of representing them in the negotiation and contracting of their health plans.
(e) The Administration may represent other interested public entities and alliances or private conglomerates that so request it.
(f) To adopt, modify and use an official seal.
(g) To establish an administrative and financial structure that will allow them to manage their funds and revenues, administer cash and make disbursements.
(h) To sue and be sued.
(i) To request, accept and receive federal, state, municipal and any other kind of contributions.
(j) To establish guidelines for the appointment, contracting and remuneration of its personnel.
(k) To negotiate and award any kind of contract, document and other public instrument with juridical persons and entities.
(l) To acquire goods, for corporate purposes, through purchase, gift, concession or bequest; to possess and exercise full property rights thereon and to dispose of them according to the terms and conditions determined by its Board of Directors.
(m) To perform all the acts that are necessary and convenient to execute the purposes of this chapter, except that the Administration shall not have the power to pledge the credit of the Commonwealth of Puerto Rico or of any of its political subdivisions.
(n) To establish in the contracts underwritten with insurers, participating providers, and health service organizations:
(1) A guarantee of the payment of the medical-hospital care received by its beneficiaries, even though it is rendered outside of the health area where the beneficiaries reside, due to an emergency or urgent need.
(2) The evaluation mechanisms and those of any other nature which will guarantee all aspects, that directly or indirectly, affect the accessibility, quality, costs control and use of services, as well as the protection of the rights of the beneficiaries and the participating purveyors.
(3) The performance as secondary payer, of the medical insurance contracted by the Administration, in the event the person eligible to receive services has other medical insurance.
(4) To bar service purveyors from billing patients directly for the balance that the insurance company did not pay out for services rendered in emergency rooms, which, as patients, they are not under the obligation to pay. Insurers shall be responsible to pay one hundred percent (100%) of the amount stipulated in their contract. This does not include deductibles.
(o) To direct the insurers, health service organizations, and participating providers to furnish the information that the Administration deems necessary to follow up on the strict compliance with this chapter, to keep a record of the services rendered in categorical programs subsidized by the federal government that have been delegated, and to document the relationship of their beneficiaries, payment claims, and the pertinent financial and statistical reports. In case of noncompliance, the Administration may resort to the Court of First Instance of Puerto Rico, San Juan Part, to request it to order the delivery of the required information.
(p) To approve, amend and repeal regulations to govern the business and activities of the Administration and to prescribe the rules and norms needed to comply with its functions and duties, as established in §§ 2101 et seq. of Title 3, known as the “Commonwealth of Puerto Rico Uniform Administrative Procedures Act”.
(q) To order all the studies that are needed to comply with the mandate of this chapter.
(r) To maintain a Continuing Education and Prevention Division for the promotion, development, emphasis, and strengthening of activities and training for the providers participating in the Health Plan to be established and managed by the Administration, according to norms and procedures thereof and the funds assigned to the same for these purposes, including but not limited to:
(1) Maintaining said participating providers informed about the operations of the system, its procedures, those changes it may undergo, and any other information related to the management of the health services provided for the beneficiaries of the Administration, according to this chapter.
In the exercise of this duty, the Administration may use communication methods or strategies, such as the publishing of an informational bulletin, press releases, or coordinating the educational and prevention seminars for such ends, among others, jointly with the Puerto Rico Surgeons Association and other associations and entities established by law, in representation of the participating providers.
History —Sept. 7, 1993, No. 72, Art. IV, § 2; June 22, 2000, No. 107, § 1; July 19, 2002, No. 105, § 3; Jan. 4, 2003, No. 64, § 1; Oct. 20, 2009, No. 128, § 1; Feb. 26, 2010, No. 20, § 1; Aug. 8, 2010, No. 123, § 3.