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) › § 9168 - Availability of coverage in the individual market—Federally defined eligible individual

(a) Notwithstanding the provisions of § 9167 of this title and subject to subsection (b) of this section and the applicable federal regulations, if an eligible individual who is a federally defined eligible individual applies for coverage under an individual health plan within sixty-three (63) days of termination of the prior creditable coverage, the individual health plan issuer may not:
(1) Decline to offer individual basic health plan, or deny enrollment of the individual, or
(2) with respect to the coverage, impose any preexisting condition exclusion, as such term is defined in this chapter, regardless of the age of the enrollee.
(b)
(1) An individual health plan issuer may elect to limit the coverage offered, if it offers at least two (2) different policy forms of individual basic health plan, both of which:
(A) Are designed for and meet the requirements of subsection (c) and comply with the provisions of § 9169 of this title and the applicable federal laws, as required in § 9005 of this title, and
(B) are made generally available to, and actively marketed by the issuer.
(2) For purposes of this subsection, policy forms that have different cost-sharing arrangements or different riders are considered to be different policy forms.
(c)
(1) An individual health plan issuer meets the requirements of subsection (b)(1)(A) if it offers a high-level and a low-level policy form, each of which:
(A) Includes benefits substantially similar to other individual health plans offered by the issuer in Puerto Rico, and
(B) is covered under a mechanism described in subsection (c)(4), relating to risk adjustment, risk spreading, or financial subsidization.
(2) For purposes of clause (1)(B), the following shall be considered a policy form:
(A) A low-level policy form, if the actuarial value of the benefits under the coverage is at least sixty percent (60%), but not greater than seventy percent (70%) of a weighted average, and
(B) a high-level policy form if:
(i) The actuarial value of the benefits under the coverage is at least fifteen percent (15%) greater than the actuarial value of the coverage described in paragraph (A) offered by the issuer in Puerto Rico, and
(ii) the actuarial value of the benefits under the coverage is at least eighty percent (80%), but not greater than ninety percent (90%) of a weighted average.
(3)
(A) For purposes of clause (2), the weighted average is the average actuarial value of the benefits provided, as determined by the issuer:
(i) Based on all the health plans issued by the issuer in the individual market during the previous year, weighted by enrollment for the different coverages, or
(ii) based on all the issuers in Puerto Rico in the individual market during the previous year, weighted by enrollment for the different coverages.
(B) The weighted average calculated under paragraph (A) shall not include health plans issued in accordance with this section.
(4) A mechanism meets the requirements of clause (1)(B) if:
(A) It provides for risk adjustment, risk spreading mechanism, or otherwise provides for some financial subsidization for federally defined eligible individuals, including through assistance to participating issuers, or
(B) it is a mechanism under which federally defined eligible individuals are provided a choice of coverage under all individual health plans the issuer otherwise has available.
(5)
(A) An election made under this subsection shall:
(i) Apply uniformly for all federally defined eligible individuals in Puerto Rico for that individual health plan issuer.
(ii) Is effective for policies offered during a period of at least two (2) years following the date of election.
(B) Pursuant to paragraph (A)(ii), after expiration of the initial election period and for the expiration of each subsequent election period, the issuer shall again make the elections in accordance with this subsection.
(6) For purposes of clause (2), the actuarial value of benefits provided under individual market coverage shall be calculated based on a standardized population and a set of standardized utilization and cost factors.
(d)
(1) A health plan issuer that offers coverage in the individual market through a preferred network plan may:
(A) Limit the individuals who may be enrolled under such coverage to those who live, reside, or work within the established geographic service area of such preferred network plan, and
(B) regarding the geographic service area of the preferred network plan, deny coverage to individuals who live, reside, or work within the established geographic service area, if the issuer demonstrates, to the satisfaction of the Commissioner, that:
(i) It will not have the capacity to deliver services adequately to additional individual enrollees because of its obligations to existing group or individual policy holders and individual enrollees, and
(ii) it is applying this clause uniformly to all individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are federally defined eligible individuals.
(2) An individual health plan issuer that cannot offer coverage in accordance with clause (1)(B), may not offer coverage in the individual market within the established geographic service area until:
(A) A period of one hundred eighty (180) days after the date of each coverage denial, or
(B) the date on which the issuer notifies the Commissioner that it can deliver services to specific individuals in the individual market, if such date is a later date than the date provided in paragraph (A).
(e)
(1) An individual health plan issuer shall not be required to provide coverage in the individual market to federally defined eligible individuals, under this subsection, if:
(A) For any period of time the Commissioner determines the individual health plan issuer does not have the financial reserves necessary to underwrite additional coverage, and
(B) the individual health plan issuer is applying this clause uniformly to all individuals in the individual market in Puerto Rico consistent with applicable Commonwealth law and without regard to any health status-related factor related to any individual and without regard to whether an individual is a federally defined eligible individual.
(2) An individual health plan issuer that denies coverage in accordance with clause (1) may not offer such coverage in the individual market until:
(A) A period of one hundred eighty (180) days after the date the coverage is denied, or
(B) the date on which the individual health plan issuer has demonstrated to the satisfaction of the Commissioner that it has sufficient financial reserves to underwrite additional coverage, if on a later date than the date provided in paragraph (A).
(f) The provisions of this section shall not be construed to require that an issuer offering health plans only in connection with group health plans or through one or more bona fide associations, or both, offer coverage in the individual market.
History —Aug. 29, 2011, No. 194, added as § 10.080 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.