2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 108 - Individual Health Plans and Guaranteed Availability (§§ 9161 — 9175) › § 9165 - Restrictions related to rates and forms

(a) Rates for individual health plans shall be subject to the provisions of the Affordable Care Act and the interpretive regulations adopted thereunder. Moreover, individual health plan issuers shall establish their rates based on the rating characteristics defined in this chapter and those established for such purposes by the Commissioner through policy letter.
(b) The Commissioner shall provide through policy letter the rules applicable to rate changes resulting from adjustments based on rating characteristics and benefit design.
(c) For purposes of this section, a preferred network plan shall not be considered a similar benefit design to that of a health plan that does not contain such a provision, if the restriction of benefits to network providers results in substantial differences in claim costs.
(d) Rates established pursuant to subsection (a)(1) of this section with respect to any individual health plan may not be changed more frequently than once a year. The premium charged to an enrollee may only be changed more than once within a twelve (12)-month period to reflect:
(1) Changes to the family composition of the enrollee, or
(2) changes to health insurance requested by the enrollee.
(e) The Commissioner may promulgate policy letters and rules to implement the provisions of this section and to assure that rating practices used by individual health plan issuers are consistent with the purposes of this chapter.
(f) As part of its solicitation and sales materials, the issuer shall make a reasonable disclosure, in connection with individual health plans, of all of the following:
(1) The manner in which rating characteristics are used to establish and adjust premium rates for an individual and his/her dependents;
(2) the issuer’s right to change premium rates and the factors, other than claim experience, that may affect changes in premium rates;
(3) the provisions relating to renewability of policy and contracts;
(4) the provisions relating to preexisting conditions, and
(5) all individual health plans offered by the insurer, the prices of the plan if available to the eligible person and the availability of the plans to the individual.
(g) Each issuer shall maintain at its principal place of business, and in digital format posted in its website and readily accessible to any person, a complete and detailed description of its rating and underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
(h) Each issuer shall file with the Commissioner annually on or before March 31 of each year, an actuarial certification certifying that the issuer is in compliance with this chapter and that the rating methods of the issuer are actuarially sound. The certification shall be in a form and manner, and shall contain such information, as specified by the Commissioner through policy letter. A copy of the certification shall be retained by the issuer at its principal place of business.
(i) An insurer shall make the information and documentation described in the above subsection available to the Commissioner upon request for his/her inspection. Except in cases of violations of any provision of this chapter, the information and documents required herein shall be considered proprietary and trade secret information and shall not be subject to disclosure by the Commissioner to persons outside of the Office of the Commissioner of Insurance, except as agreed to by the issuer or as ordered by a court with jurisdiction. Notwithstanding the provisions of this section, rates charged by the issuer shall not be considered as proprietary information.
(j) The individual health plan issuer shall file with the Commissioner the individual basic health plans in their different metal levels of coverage, following the procedure established in §§ 1101-1137 of this title and the format provided by the Commissioner through policy letter. The issuer may use the individual health insurance filed in accordance with this subsection ninety (90) days after the filing date, unless the Commissioner does not approve the use thereof.
(k) Issuers shall not modify an individual health plan approved with respect to an enrollee or his/her dependents through riders, endorsements, or surcharges based on their health status or claim experience nor shall exclude coverage or benefits related to specific diseases or medical services or conditions that would otherwise be covered under the health plan.
(l) The Commissioner at any time may, after providing notice and an opportunity for a hearing, disapprove the use of an individual health plan already approved if such plan fails to comply with the provisions of this chapter or the applicable federal legislation.
(m) Starting on January 1, 2014, no individual health plan shall deny, exclude or limit the benefits of a covered person based on preexisting conditions, regardless of the age of the enrollee.
History —Aug. 29, 2011, No. 194, added as § 10.050 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.