2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9167 - Availability of coverage under a conversion privilege clause from a group health plan to a converted policy

(a)
(1) As a condition of transacting insurance in Puerto Rico, individual health plan issuers shall offer approved basic health plans in its different metal levels of coverage to recently insured individuals who apply for an individual health plan and agree to make premium payments and satisfy the other reasonable requirements of such individual health plan.
(2) If the recently insured individual had qualifying previous coverage with benefits that are not similar to or exceed those provided under the Silver individual basic health plan, the issuer may offer the individual Bronze individual basic health plan to such recently insured individual, who converts his/her policy between enrollment periods, until the next enrollment period. During the enrollment period, the enrollee may elect his/her basic health plan of preference.
(3) An issuer shall not be required to issue an individual basic health plan in its different metal levels of coverage to a recently insured individual who:
(A) Does not apply for an individual basic health plan within thirty (30) days of a qualifying event or within thirty (30) days after becoming ineligible for qualifying existing coverage;
(B) is covered or is eligible for coverage under a health plan that provides health care coverage that is provided by an employer of the recently insured individual. A converted policy is not considered a benefit plan provided by an employer for purposes of this clause;
(C) is covered or is eligible for coverage under a health plan that provides healthcare coverage in which the spouse, father, mother, or guardian is enrolled or eligible to be enrolled, except if such health plan is the Government Health Plan known as “Mi Salud” or any other government plan administered by the Health Insurance Administration;
(D) for the duration of the coverage, in accordance with the prior individual health plan and which terminates after the effective date of the new coverage;
(E) is covered or is eligible for coverage, under any private or public health benefit arrangement, including a Medicare supplement policy or the Medicare program established under Title XVIII of the Social Security Act, 49 Stat. 620 (1935), 42 U.S.C. 301, as amended, or any other Federal or Commonwealth law, except for a Medicare-eligible individual for reasons other than age; or
(F) is covered or is eligible for any continued group health plan under Section 4980b of the U.S. Internal Revenue Code, 26 U.S.C. 4980b, Sections 601 through 608 of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, Sections 2201 through 2208 of the Public Health Services Act, as amended, or any other continued group health plan required by law.
(b) Upon an issuer notifying an enrollee, who is a resident of Puerto Rico, of a premium rate increase on the individual health plan, any other private health plan issuer may issue at the option of the enrollee, an individual basic health plan in its different metal levels of coverage, if the enrollee exercises his/her option within ninety (90) days of receiving the notification and the enrollee terminates existing coverage.
(c) Issuers shall not be required to offer coverage or accept applications, pursuant to subsection (a) of this section, from an eligible person who does not reside in the issuer’s established geographic service area.
(d) The Commissioner shall have the duty to establish through policy letter the procedures for the conversion of policies and the applicability and scope of this section for issuers that are not engaged in marketing policies in the individual market.
History —Aug. 29, 2011, No. 194, added as § 10.070 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.