reglab/statecodes huggingface dataset:
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9126 - Renewability of health plan

(a) An issuer providing health plans to PYMES employers shall renew the same to all eligible employees and their dependents, except in any of the following cases:
(1) Failure to pay premiums, considering the grace period.
(2) When the covered person or enrollee has performed an act that constitutes fraud. In such case the issuer may choose not to renew the health plan of such covered person or enrollee for one (1) year as of the of the [sic] coverage’s termination date.
(3) When the covered person or enrollee has or made an intentional misrepresentation of material fact under the terms of coverage. In such case the issuer may choose not to renew the health plan of such covered person or enrollee for one (1) year as of the of the [sic] coverage’s termination date.
(4) Noncompliance with the issuer’s minimum participation requirements, pursuant to the provisions of this chapter.
(5) Noncompliance with the issuer’s employer contribution requirements.
(6) When the issuer elects to discontinue offering all of its health plans to PYMES employers in Puerto Rico. In these cases, the issuer shall provide a written notice to the Commissioner, the PYMES employer, and the covered persons or enrollees, of its decision not to renew coverage at least one hundred and eighty (180) days prior to the nonrenewal of the health plans. The issuer that elects to discontinue offering health plans, as provided herein, shall be impaired from underwriting new business in the PYMES employer market in Puerto Rico for a term of five (5) years, beginning on the date in which the issuer ceased to offer such health plans.
(7) When the commissioner finds that the continuation of the coverage would not be in the best interests of the policyholders or would impair the issuer’s ability to meet its contractual obligations.
(8) In the case of health plans that are made available in the small group market through a preferred network plan, there is no longer an employee of the PYMES employer living, working, or residing within the issuer’s established geographic service area.
(b) In the case of a PYMES employer issuer doing business in one established geographic service area of Puerto Rico, the rules set forth in this section shall apply only to the issuer’s operations in that service area.
(c) In addition to comply with the provisions of this section, the issuer shall comply, at all times, with the applicable federal regulations, as codified under 45 C.F.R. Section 146.152 (Guaranteed renewability of coverage for employers in the group market).
History —Aug. 29, 2011, No. 194, § 8.060, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9128 - Certification of creditable coverage

(a) PYMES employer issuers shall provide written certification of creditable coverage to individuals in accordance with subsection (b) of this section.
(b) The certification of creditable coverage shall be provided:
(1) At the time an individual ceases to be covered under the health plan or otherwise becomes covered under a COBRA continuation provision.
(2) In the case of an individual who becomes covered under a COBRA continuation provision at the time the individual ceases to be covered under that provision.
(c) The certificate of creditable coverage required to be provided pursuant to section shall contain:
(1) The period of creditable coverage of the individual under the other health plan, and
(2) the waiting period, if any, and, if applicable, affiliation period imposed with respect to the individual for any coverage under another health plan.
History —Aug. 29, 2011, No. 194, § 8.080, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9129 - Repealed. Act July 10, 2013, No. 55, § 18, eff. 30 days after July 10, 2013

History Aug. 29, 2011, No. 194, —Aug. 29, 2011, No. 194, § 8.090, eff. 180 days after Aug. 29, 2011; Act July 10, 2013, No. 55, § 18, eff. 30 day after July 10, 2013, effective July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9130 - Transitory provisions for issuers offering health plans to PYMES employers

(a) Issuers interested in offering and marketing, or who wish to continue offering and marketing the health plans authorized under this chapter, or any other designed for PYMES employers in Puerto Rico, shall comply with the following:
(1) As a transition measure, and while the provisions of this chapter are implemented entirely, it is hereby provided that any issuer that is offering, marketing, or administering any health plan for one or more PYMES employers at the time of the approval of this act may continue to do so.
(2) The preceding clause notwithstanding, such issuer shall provide, within a term of thirty (30) days, a notice to the Commissioner stating:
(A) The date on which it began offering, marketing or administering health plans for PYMES employers.
(B) the number of health plan models available for PYMES employers, classified as marketed, exclusive or administered, and if the latter has any stop loss coverage;
(C) the number of PYMES employers and enrollees that are enrolled by type of health plan, following the aforementioned classification;
(D) rate or rates for these health plans and the basis to determine the same, as well as those used and underwritten;
(E) a table itemizing the covered benefits, exclusions, and limitations, applicable deductible, copayments and coinsurance, eligible employees and dependents, and premiums applicable for individuals, family groups, the employee and one dependent (partner), for optional dependents or collaterals, as such terms and practices are commonly accepted and defined in the health insurance market, and
(F) any other information that may be necessary to achieve the purposes of this chapter.
(b) It is hereby further provided, that every issuer that, at the time of the approval of this chapter has underwritten any health plan for a PYMES employer, may continue to renovate the same, as provided in the applicable federal regulations, codified under 45 C.F.R. Section 146.152 (Guaranteed renewability of coverage for employers in the group market) and 147.140 (Preservation of right to maintain existing coverage), promulgated pursuant to Public Law 111-148, known as the Patient Protection and Affordable Care Act, and Public Law 111-152, known as the Health Care and Education Reconciliation Act.
History —Aug. 29, 2011, No. 194, § 8.100, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 19, eff. 30 days after July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9131 - Repealed. Act July 10, 2013, No. 55, § 18, eff. 30 days after July 10, 2013

History Aug. 29, 2011, No. 194, —Aug. 29, 2011, No. 194, § 8.110, eff. 180 days after Aug. 29, 2011; Act Aug. 9, 2013, No. 55, § 20, effective July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9132 - Basic health plan

(a) The Commissioner shall authorize the manner and level in which the PYMES employer issuer shall provide coverage according to this chapter and the provisions of § 9005 of this title.
(b) The Commissioner shall provide the benefit levels, cost-sharing, exclusions, and limitations of the basic health plan in its different metal levels or variations, taking into account all the provisions imposed by state and federal laws and regulations. Health plans authorized by the Commissioner shall include cost control measures such as the following:
(1) Utilization review of healthcare services, including review of medical necessity of hospital and physician services;
(2) improve quality and access to services, preventive programs and case management, among others;
(3) selective contracting with hospitals, physicians and other healthcare providers;
(4) reasonable benefit differentials applicable to providers that participate or do not participate in arrangements using preferred network provisions, and
(5) other managed care provisions.
(c) The Commissioner may establish, through policy letter, the requirements of a basic health plan in its different metal levels, as well as other health plans he/she deems convenient to fulfill the purposes described in this section. After this initial recommendation, and at least once a year, the Commissioner shall promulgate the necessary amendments to such health plans.
History —Aug. 29, 2011, No. 194, § 8.120, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 21, eff. 30 days after July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9133 - Periodic market evaluation

The Commissioner shall conduct a study at least every three (3) years on the effectiveness of the provisions of this chapter. The report shall analyze the effectiveness of the provisions of this chapter in promoting rate stability, product availability, and coverage affordability of health plans for PYMES employers. The report may contain recommendations for improvements to the overall effectiveness, efficiency, and fairness of the small group health insurance market. The report shall address whether issuers and producers are fairly and actively marketing or issuing health plans to PYMES employers in accordance with the purposes of the chapter. The report may contain recommendations regarding market conduct or other regulatory standards or actions.
History —Aug. 29, 2011, No. 194, § 8.130, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 22, eff. 30 days after July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9134 - Waiver of certain Commonwealth laws

No Commonwealth law or regulation approved after the effective date of this chapter requiring the coverage of a healthcare service or benefit, or requiring the reimbursement, utilization or inclusion of a specific category of healthcare provider or person, shall apply to the health plans delivered by PYMES employer issuers in Puerto Rico, unless as otherwise provided by the law or regulation in question. However, any issuer may elect to comply with the provisions of the law or approved regulation, if doing so inures to the benefit of PYMES employers, as well as their employees and the dependents thereof.
History —Aug. 29, 2011, No. 194, § 8.140, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9135 - Administrative procedures

The Commissioner shall issue policy letters or regulations as necessary for the implementation of the provisions of this chapter following the procedure established therefor in §§ 201-232 of this title.
History —Aug. 29, 2011, No. 194, § 8.150, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 23, eff. 30 days after July 10, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9136 - Standards to assure fair marketing

(a) Each issuer shall actively market all health plans sold by the issuer to all PYMES employers in Puerto Rico.
(b) No PYMES employer issuer or producer shall, directly or indirectly, engage in the following activities:
(1) Encouraging or directing PYMES employers to refrain from filing an application for coverage with the PYMES employer issuer because of any health status-related factor, industry, occupation or geographic location of the PYMES employer. This provision shall not apply with respect to information provided by a PYMES employer issuer or producer regarding the established geographic service area or a preferred network provision.
(c) No issuer shall, directly or indirectly, enter into any contract, agreement or arrangement with a producer that provides for or results in the compensation paid to a producer for the sale of a health plan to be varied because of any initial or renewal health status-related factor of eligible employees or dependents, or industry, occupation or geographic location of the PYMES employer. This provision shall not apply with respect to a compensation arrangement that provides compensation to a producer on the basis of percentage of premium, provided that the percentage shall not vary because of any health status-related factor of eligible employees or dependents, or industry, occupation or geographic location of the PYMES employer.
(d) No issuer may terminate, fail to renew or limit its contract or agreement of representation with a producer for any reason related to any initial or renewal health status-related factor of eligible employees or dependents, or industry, occupation or geographic location of the PYMES employer placed by the producer.
(e) An issuer or producer may not induce or otherwise encourage a PYMES employer to separate or otherwise exclude an eligible employee or dependent from the benefits of a health plan.
(f) Denial by an issuer of an application for health plan from a PYMES employer, for any of the reasons permitted in accordance with the provisions of this chapter, shall be in writing and shall state the reason or reasons for the denial.
(g) Any violation of this section shall be an unfair trade practice under §§ 2701–2740 of this title and shall be subject to the sanctions provided therein. If an issuer enters into a contract, agreement or other arrangement with a third-party administrator to provide administrative, marketing or other services related to the offering of health plans to PYMES employer in Puerto Rico, the third-party administrator shall be subject to this section as if it were an issuer.
History —Aug. 29, 2011, No. 194, § 8.160, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 106 - Small and Medium-sized Businesses Employer Health Insurance Availability (§§ 9121 — 9137) › § 9137 - Required disclosure

(a) In connection with the offering for sale of any health plan to a PYMES employer, the issuer shall make a reasonable disclosure, as part of its solicitation and sales materials, of all of the following:
(1) The provisions of the health plan that, in accordance with this chapter, grant the issuer the right to change rates and the factors therefor, other than claim experience.
(2) The provisions related to the possibility of renewal of policies and contracts.
(3) The provisions related to preexisting conditions.
(4) A listing and descriptive information, including benefits and premiums, on all health plans available for PYMES employers.
History —Aug. 29, 2011, No. 194, § 8.170, eff. 180 days after Aug. 29, 2011.
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) › § 9161 - Title

This chapter shall be known and cited as the Chapter on Individual Health Plan and Guaranteed Availability.
History —Aug. 29, 2011, No. 194, added as § 10.010 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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) › § 9162 - Public policy

The purpose of this chapter is to enhance the availability of health insurance coverage to persons who are not insured under an employer or labor union group health plan, regardless of their health status or claim experience; to prevent abusive rating practices; to require disclosure of rating practices in the individual market; to establish rules regarding renewability of coverage; eliminate the use of preexisting condition exclusions; provide for the development of individual basic health plans in their various metal levels of coverage; promote and guarantee equal access to health plans; improve overall fairness and efficiency in the individual health plan market; and regulate the guaranteed availability of policies in the individual market through the implementation of an enrollment period.
History —Aug. 29, 2011, No. 194, added as § 10.020 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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) › § 9164 - Applicability and scope

(a) The provisions of this chapter concerning individual health plans and the issuers that offer them shall apply to:
(1) Individual health plan offered to and that covers enrollees and their dependents who are residents of Puerto Rico or dependents who study and reside outside of Puerto Rico at the time of issue, regardless of the number of health plans that the enrollee has. In the case of guaranteed availability required by this chapter, the same shall apply to such individual health plans, if the enrollee is not covered and is not eligible for an employee-sponsored group health plan;
(2) any certificate issued to an enrollee that evidences coverage under a policy or contract issued to a trust or association or other similar grouping of individuals, which are not contingent on employer relation, regardless of the situs of delivery of the policy or contract, if the enrollee pays the premium and is not covered under the policy or contract pursuant to continuation of benefits provisions applicable under federal and Commonwealth laws;
(3) bona fide association plans as set forth in this chapter, and
(4) converted policies as set forth in this chapter.
(b) For the purposes of this chapter, except as provided in subsection (c), issuers that are affiliated companies or that are eligible to file a consolidated income tax return shall be treated as one issuer, and any restrictions or limitations imposed by this chapter shall apply as if all individual health plans delivered or issued for delivery to residents of Puerto Rico by affiliated issuers were issued by one issuer.
(c) Any affiliated issuer who is a health services organization having a certificate of authority issued pursuant to the provisions of the Insurance Code of Puerto Rico or under this subtitle shall be considered to be a separate issuer for the purposes of this chapter.
(d) The Commissioner shall have the authority, pursuant to § 9008 of title, to impose sanctions. Likewise, the Commissioner shall have the power to prosecute administratively and judicially any violation of §§ 233-257 of this title.
History —Aug. 29, 2011, No. 194, added as § 10.040 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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) › § 9169 - Health plan standards

The Commissioner shall provide through policy letter the form and level of coverage of the basic health plan in its different metal plans options for the individual market, so as to comply with the federal provisions and provide, at least, the Essential Health Benefit Package in accordance with § 9005 of this title, which shall be appropriately adjusted to reflect the individual market.
History —Aug. 29, 2011, No. 194, added as § 10.090 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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) › § 9170 - Certification of creditable coverage

(a) Individual health plan issuers offering individual health plans shall provide written certification of creditable coverage to all individuals in accordance with subsection (b).
(b) The certification of creditable coverage shall be provided:
(1) At the time an individual ceases to be covered under the health plan or otherwise becomes covered under a Consolidated Omnibus Budget Act of 1986 (COBRA) continuation provision;
(2) in the case of an individual who becomes covered under a Consolidated Omnibus Budget Act of 1986 (COBRA) continuation provision, at the time the individual ceases to be covered under that provision, and
(3) at the time a request is made on behalf of an individual if the request is made not later than twenty-four (24) months after the date of cessation of coverage described in clause (1) or (2), whichever is later.
(c) Individual health plan issuers may provide the certificate of creditable coverage required in subsection (b)(1) consistent with the applicable Consolidated Omnibus Budget Act of 1986 (COBRA) continuation provisions.
(d) The Commissioner shall establish through policy letters all the requirements that any certification of creditable coverage required under subsection (a) shall contain, subject to the applicable federal regulations regarding the content of such document, the requirements for issue, and the use thereof.
History —Aug. 29, 2011, No. 194, added as § 10.100 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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) › § 9171 - Standards to assure fair marketing

(a)
(1) If an issuer denies individual health plan coverage to an eligible person on the basis of his/her health status or claims experience or that of his/her dependents, the issuer shall offer such person the opportunity to purchase an approved basic health plan in any of its different metal levels of coverage.
(2) Except as provided in §§ 9167 and 9168 of this title, and notwithstanding the provisions of clause (1), individual health plan issuers may not deny coverage to an applicant who is an eligible person or a federally defined eligible individual.
(b) Except as provided in subsection (c) of this section, no issuer, producer, or any other intermediary shall, directly or indirectly, engage in any of the following activities:
(1) Encourage or direct individuals to refrain from filing an application for coverage with the issuer because of the health status, claims experience, industry, occupation, or geographic location of the individual.
(2) Encourage or direct individuals to seek coverage from another issuer because of the health status, claims experience, industry, occupation, or geographic location of the individual.
(c) The provisions of subsection (b)(1) shall not apply with respect to information provided by an issuer or producer to an individual regarding the established geographic service area of the issuer or a preferred network provision of the issuer.
(d) Except as provided in subsection (e) of this section, no issuer shall, directly or indirectly, enter into any contract, agreement, or arrangement with a producer that provides for the compensation paid to a producer for the sale of a health plan to be varied because of the health status or permitted ratings characteristics of the individual or his/her dependents.
(e) Subsection (d) shall not apply with respect to a compensation arrangement to a producer on the basis of percentage of premium, provided that the percentage shall not vary because of the health status or other permitted rating characteristics of the individual or his/her dependents.
(f) Denial by an issuer of an application for coverage shall be in writing and shall state the reasons for the denial.
(g) A violation of this section by an issuer or a producer shall be an unfair trade practice under §§ 2701-2736 of this title.
(h) If an issuer enters into a contract, agreement, or other arrangement with a Third-party Administrator to provide administrative, marketing, or other services related to the offering of individual health plans in Puerto Rico, the Third- party Administrator shall be subject to this section as if it were an issuer.
(i) In addition to the provisions of this section, an issuer shall comply at all times with the applicable federal regulations.
History —Aug. 29, 2011, No. 194, added as § 10.110 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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) › § 9173 - Participation in employer-sponsored health plans

A health plan sponsored and paid by an employer qualified under the Employee Retirement Income Security Act of 1974 (ERISA), as amended, specifically basic health plans for PYMES employers in any of its different metal levels of coverage may participate in the Health Plan Issuer Association established in § 9172 of this title in accordance with the plan of operation and subject to the terms and conditions to be adopted by the Board of the Association.
History —Aug. 29, 2011, No. 194, added as § 10.130 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
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) › § 9174 - Special rules related to converted policies

(a) Upon the approval of the basic health plans in the different metal levels of coverage in accordance with § 9169 of this title, all issuers required to offer a converted policy to an individual, pursuant to the provisions of this Code, may offer as a converted policy a choice of the individual basic health plans only.
(b) If an issuer offers two or more options of individual basic health plan as a conversion coverage in accordance with subsection (a), then the issuer shall be eligible to receive distributions pursuant to the Health Plan Association for the individual basic converted policies in accordance with § 9172 of this title.
(c) If an issuer offers two or more options of individual basic health plan as a conversion coverage in accordance with subsection (a), then the individual with a converted policy issued before the effective date of the requirement under subsection (a) shall be entitled to elect an individual basic health plan as a substitute converted policy at each annual renewal of the converted policy.
(d) The Commissioner shall provide through policy letter the rules to rate converted policies in accordance with this chapter, and to rate converted policies that provide medical coverage similar to or exceeding that of health plans.
(e) The Commissioner shall issue and promulgate policy letters, as well as regulations as necessary for the implementation of this section.
History —Aug. 29, 2011, No. 194, added as § 10.140 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9201 - Title

This chapter shall be known and may be cited as the chapter on the Prohibition on the Use of Discretionary Clauses.
History —Aug. 29, 2011, No. 194, § 12.010, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9202 - Purpose

The purpose of this chapter is to assure that health insurance benefits and disability income protection coverage are contractually guaranteed so as to prevent the conflict of interest that occurs when health insurance organizations or issuers have discretionary authority to decide what benefits are due. Nothing in this chapter shall be construed as imposing any requirement or duty on any person other than a health insurance organization or issuer that offers disability income protection coverage.
History —Aug. 29, 2011, No. 194, § 12.020, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9203 - Definitions

(a) Disability income protection coverage.— Is a policy, contract, certificate or agreement that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination of them.
(b) Healthcare services.— Means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
History —Aug. 29, 2011, No. 194, § 12.030, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 110 - Prohibition on the Use of Discretionary Clauses (§§ 9201 — 9204) › § 9204 - Discretionary clauses prohibited

(a) No policy, contract, certificate or agreement offered or issued in Puerto Rico by a health insurance organization or issuer to provide, deliver, arrange for, pay for or reimburse any of the costs of healthcare services may contain a provision purporting to reserve discretion to health insurance organizations or issuers to interpret the terms of the contract, or to provide standards of interpretation or review that are inconsistent with the laws of Puerto Rico. An adverse determination by a health insurance organization or issuer, as well as disputes or controversies that may arise between a health insurance organization or issuer and a covered person or enrollee, shall be subject to the internal and external review procedures established in this Code.
(b) No policy, contract, certificate or agreement offered or issued in Puerto Rico providing for disability income protection coverage may contain a provision purporting to reserve discretion to the insurer to interpret the terms of the contract, or to provide standards of interpretation or review that are inconsistent with the laws of Puerto Rico.
History —Aug. 29, 2011, No. 194, § 12.040, eff. 180 days after Aug. 29, 2011.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9231 - Title

This chapter shall be known and may be cited as the Chapter on Health Information Protection.
History —Aug. 29, 2011, No. 194, added as § 14.010 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9232 - Purpose

The purpose of this chapter is to establish standards for the protection of the health information of covered persons or enrollees requiring health insurance organizations and issuers to establish procedures for the proper management of any health information generated, maintained, used or disclosed as part of their operations. Any provision of this chapter that is in conflict with the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996, as amended, or any applicable federal law, shall be deemed amended to be consistent with the applicable federal law and rule.
History —Aug. 29, 2011, No. 194, added as § 14.020 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9234 - Applicability and scope

This chapter applies to all health insurance organizations or issuers and governs the management of health information, including the collection, use, and disclosure of protected health information by health insurance organizations or issuers.
History —Aug. 29, 2011, No. 194, added as § 14.040 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9235 - Health information policies, standards and procedures

(a) A health insurance organization or issuer shall develop and implement written policies, standards, and procedures for the management of health information, in order to guard against the unauthorized collection, use, or disclosure of protected health information. It shall meet the applicable requirements of the Federal Privacy and Security Rules issued in accordance to HIPAA. Such policies, standards, and procedures shall include:
(1) Limitation on access to health information based on the functions of its employees;
(2) appropriate training for all employees;
(3) disciplinary measures for violations of the health information policies, standards, and procedures;
(4) identification of the job titles and job descriptions of persons that are authorized to disclose protected health information;
(5) procedures for authorizing and restricting the collection, use, or disclosure of protected health information;
(6) methods for exercising the right to access and amend protected health information, as provided in §§ 9237 and 9238 of this title;
(7) methods for handling, disclosing, storing, and disposing of health information;
(8) periodic monitoring of the employees' compliance with the health insurance organization or issuer's policies, standards, and procedures, and
(9) methods for informing and allowing an individual who is the subject of protected health information to request specialized disclosure or nondisclosure of protected health information, as required under § 9244 of this title.
(b)
(1) A health insurance organization or issuer shall take the necessary measures to assure that any person or entity with which it contracts to carry out functions related to the collection, disclosure, management, or use of protected health information complies with the following:
(A) Has policies, standards, and procedures that meet the requirements of this chapter regarding health information, and
(B) knows its obligation to meet any applicable Commonwealth and federal statutory and regulatory requirements governing the collection, use or disclosure of protected health information.
(2) In any contractual arrangement between the health insurance organization or issuer and a provider, the health insurance organization or issuer shall require that the healthcare provider have health information privacy policies, standards and procedures.
(c) A health insurance organization or issuer shall make the health information policies, standards and procedures developed pursuant to this section available for review and inspection by the Commissioner.
History —Aug. 29, 2011, No. 194, added as § 14.050 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9236 - Notice of health information policies, standards, and procedures

(a) A health insurance organization or issuer shall draft a written notice of its health information policies, standards, and procedures, which shall be made available for review and inspection by the Commissioner. The notice shall include:
(1) The collection, use, and disclosure of protected health information prohibited and permitted by this chapter;
(2) the procedures for authorizing and limiting disclosures of protected health information and for revoking authorizations;
(3) the procedures for accessing and amending protected health information, and
(4) the right of a covered person or enrollee to review a copy of the health insurance organization or issuer's health information policies, standards and procedures.
(b) The health insurance organization or issuer shall provide the notice to any covered person or enrollee at the time the policy is first delivered, and to any other person upon request.
History —Aug. 29, 2011, No. 194, added as § 14.060 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9239 - List of disclosures of protected health information

(a) A health insurance organization or issuer shall provide, upon request, to an individual who is the subject of the protected health information, information regarding disclosure of that individual's protected health information that is sufficient to exercise the right to amend the information pursuant to § 9238 of this title. This information shall include the date, purpose, recipient, and relevant authorization or basis for the disclosure. The health insurance organization or issuer may charge a reasonable fee for providing the information regarding the disclosures of information.
(b) The list shall not include the following disclosures:
(1) Disclosures related to healthcare payment, treatment, and operations;
(2) disclosures made or authorized by the individual;
(3) disclosures made for purposes of national security or intelligence services, and
(4) disclosures to penal institutions or law enforcement officers.
(c) A health insurance organization or issuer shall maintain a system that allows the Commissioner to determine that the health insurance organization or issuer can actually produce a complete list of disclosures.
(1) For routine disclosures, a health insurance organization or issuer shall be able to track when routine disclosures are made, to whom they are made and for what purpose they are made, and
(2) for all other disclosures, a health insurance organization or issuer shall be able to identify the authorization or release form or provision of law allowing the receipt or disclosure of protected health information.
History —Aug. 29, 2011, No. 194, added as § 14.090 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9243 - Unauthorized collection, use or disclosure of protected health information

An unauthorized collection, use, or disclosure of protected health information by a health insurance organization or issuer is hereby prohibited. Such collection, use, or disclosure shall be subject to the penalties set forth in § 9245 of this title. An unauthorized collection, use, or disclosure shall include:
(a) Unauthorized publication of protected health information;
(b) unauthorized collection, use or disclosure of protected health information for personal or professional gain, including unauthorized research that does not meet the requirements of this chapter;
(c) unauthorized sale of protected health information;
(d) unauthorized manipulation of encrypted health information that reveals protected health information, and
(e) use of deception, fraud, or threat to procure authorization to collect, use or disclose protected health information.
History —Aug. 29, 2011, No. 194, added as § 14.130 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9244 - Right to limit disclosures

(a) A health insurance organization or issuer shall limit disclosure of information, including protected health information, if the individual subject of such information clearly states in writing that disclosure to specified individuals of all or part of that information could jeopardize his/her safety. Disclosure of information shall be limited consistent with the individual's request, such as a request for the health insurance organization or issuer to not release any information to a spouse to prevent domestic violence.
(b) Except as otherwise required by law, if the individual who is the subject of the protected health information makes a written request, a health insurance organization or issuer shall not disclose protected health information concerning health services related to reproductive health, sexually transmitted diseases, substance abuse and behavioral health, including mailing appointment notices, calling the home to confirm appointments, or mailing a bill or explanation of benefits to a policyholder or certificate holder. The written request shall include information as to how any amounts payable by the individual will be handled.
(c)
(1) A health insurance organization or issuer shall recognize the right of any minor who may obtain healthcare without the consent of a parent or legal guardian pursuant to Commonwealth or federal law, to exclusively exercise rights granted under this chapter regarding health information, and
(2) a health insurance organization or issuer shall not disclose any protected health information related to any healthcare service to which the minor has lawfully consented, including mailing appointment notices, calling the home to confirm appointments, or mailing a bill or explanation of benefits to a policyholder or certificate holder, without the express authorization of the minor.
History —Aug. 29, 2011, No. 194, added as § 14.140 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 112 - Health Information Protection (§§ 9231 — 9245) › § 9245 - Sanctions

(a) Civil sanctions.—
(1) Whenever the Commissioner has reason to believe that a person has committed negligence in violation of the provisions of this chapter and that an action is in the public interest, the Commissioner may bring an action to enjoin such violations. An injunction issued under this section shall be issued without bond.
(2) In addition to the relief available pursuant to clause (1) of this subsection, the Commissioner may request and the court may order any other temporary or permanent relief as may be in the public interest, including any of the following, or any combination of the following:
(A) A civil penalty of not more than the thousand dollars ($10,000) for each violation, not to exceed fifty thousand dollars ($50,000) in the aggregate for multiple violations;
(B) a civil penalty of not more than two hundred fifty thousand dollars ($250,000) if the court finds that violations of this chapter have occurred with sufficient frequency, and
(C) reasonable attorney fees, investigation and court costs.
(b) Criminal sanctions.—
(1) The penalties described below shall apply to any natural or juridical person that collects, uses, or discloses protected health information in knowing violation of this chapter and the applicable privacy laws and regulations.
(2)
(A) A fine of not more than fifty thousand dollars ($50,000), imprisonment for not more than one (1) year; or both;
(B) If the violation is committed under false pretenses, a fine of not more than two hundred fifty thousand dollars ($250,000), imprisonment for not more than five (5) years, or any combination of these penalties, or
(C) if the violation is committed with the intent to sell, transfer or use protected health information for malicious harm, a fine of not more than five hundred thousand dollars ($500,000), imprisonment for not more than ten (10) years, or any combination of these penalties.
(c) In the event that a health insurance organization or issuer is being sued in connection with an unauthorized disclosure under a theory of vicarious liability for the actions or omissions of the health insurance organization or issuer's employees, it shall be an affirmative defense that the health insurance organization or issuer substantially met the requirements of § 9235 of this title.
History —Aug. 29, 2011, No. 194, added as § 14.150 on Aug. 23, 2012, No. 203, § 1, eff. 90 days after Aug. 23, 2012.
2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 114 - Limited Health Service Organization (§§ 9271 — 9296) › § 9271 - Title

This chapter shall be known and may be cited as the chapter on Limited Health Service Organizations.
History —Aug. 29, 2011, No. 194, added as § 16.010 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.