2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9166 - Renewability of coverage

(a) An individual health plan issuer shall be renewable or shall continue in force the coverage for the enrollee and his/her dependent, at the option of the enrollee, and in accordance with the applicable federal regulations and legislation, except in the following cases:
(1) The enrollee has failed to pay premiums or contributions in accordance with the terms of the health plan or the issuer has not received timely premium payments.
(2) The enrollee or his/her representative has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact.
(3) The issuer elects to discontinue offering individual health plans delivered or issued in Puerto Rico; and, in addition, the issuer also:
(A) Provides written notice of its decision not to renew coverage at least ninety-five (95) days prior to the nonrenewal date, to the Commissioner.
(B) Provides written notice of its decision not to renew coverage at least ninety (90) days prior to the nonrenewal date, to all enrollees.
(4) If the Commissioner finds that the continuation of the coverage would not be in the best interests of the enrollees or would impair the issuer’s ability to meet its contractual obligations.
(5) The Commissioner finds that the product form is obsolete and is being replaced with comparable coverage and the issuer decides to discontinue offering that obsolete product form in Puerto Rico; in addition the issuer:
(A) Provides advance notice of its decision not to renew the obsolete product form to the Commissioner at least one hundred eighty-five (185) days prior to the nonrenewal date;
(B) provides notice of the decision not to renew coverage at least one hundred eighty (180) days prior to the nonrenewal date to all enrollees;
(C) offers to each enrollee of the obsolete product form the option to purchase all other health plans currently being offered by the issuer in Puerto Rico, and
(D) in exercising the option to discontinue that particular obsolete product form and in offering the option of coverage pursuant to paragraph (C), the issuer acts uniformly without regard to the claims experience or any health status-related factor of the enrollees or their beneficiaries who may be eligible for coverage.
(6) In the case of health plans that are made available in the individual market only through one or more bona fide associations, the membership of an individual in the association on the basis of which the coverage is provided ceases, provided the coverage is terminated under this paragraph uniformly without regard to any health status-related factor relating to the enrollee.
(7) In the case of a health plan that offers coverage through a preferred network plan, the enrollee no longer lives, resides, or works within the issuer’s established geographic service area, provided the coverage is terminated under this paragraph without regard to any health status-related factor relating to the enrollee.
(b)
(1) Any individual health plan issuer that elects to discontinue offering health plans pursuant to subsection (a)(3) shall be prohibited from writing new business in the individual market in Puerto Rico for a period of five (5) years beginning on the date the issuer ceased offering new coverage in Puerto Rico.
(2) In the case of a discontinuance under subsection (b)(1), the individual health plan issuer, as authorized or required by the Commissioner, may renew or not renew its existing business in the individual market in Puerto Rico.
(c) In the case of a health plan issuer doing business in one established geographic service area in Puerto Rico, the provisions of this section shall apply only to the issuer’s operations in that service area.
History —Aug. 29, 2011, No. 194, added as § 10.060 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.