2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 124 - Managed Care Plan Network Adequacy (§§ 9461 — 9471) › § 9465 - Network adequacy

(a) Any health insurance organization or issuer providing a managed care plan shall maintain a network that is sufficient in numbers and types of providers to assure that all services to covered persons or enrollees will be accessible without unreasonable delay.
(b) Covered persons or enrollees shall have access to emergency services twenty-four (24) hours per day, seven (7) days per week.
(c) Sufficiency shall be determined in accordance with the requirements of this section, and may be established by reference to any reasonable criteria used by the health insurance organization or the issuer, including but not limited to: provider-covered person or enrollee ratios by specialty; primary care provider-covered person or enrollee ratios; geographic accessibility; waiting times for appointments with participating providers; hours of operation; and the volume of technological and specialty services available to serve the needs of covered persons or enrollees requiring technologically advanced or specialty care.
(1) In any case where the health insurance organization or issuer has an insufficient number or type of participating provider to provide a covered benefit, such health insurance organization or issuer shall ensure that the covered person or enrollee obtains the covered benefit at the same cost to the covered person or enrollee than if the benefit were obtained from participating providers.
(2) The health insurance organization or issuer shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers to the business or personal residence of covered persons or enrollees. In determining whether a health insurance organization or issuer has complied with this provision, the Commissioner shall give due consideration to the relative availability of healthcare providers in the service area under consideration.
(3) A health insurance organization or issuer shall monitor the ability, clinical capacity, financial capability and legal authority of its providers to furnish all contracted benefits to covered persons or enrollees.
(d) Beginning on the effective date of this chapter, a health insurance organization or issuer shall file with the Commissioner an access plan meeting the requirements of this chapter for each of the managed care plans that the issuer offers in Puerto Rico. Any access plan of health insurance organizations or issuers shall be made available on its business premises and shall provide them to any interested party upon request. The health insurance organization or issuer shall devise an access plan prior to offering a new managed care plan and update the existing plan whenever it makes a material change to an existing managed care plan. The access plan shall describe or contain at least the following:
(1) The health insurance organization or issuer’s network;
(2) the health insurance organization or issuer’s procedures for making referrals within and outside its network;
(3) the health insurance organization or issuer’s process for monitoring and assuring the sufficiency of the network to meet the healthcare needs of populations that enroll in managed care plans;
(4) the health insurance organization or issuer’s efforts to address the needs of covered persons or enrollees who are illiterate or have diverse cultural and ethnic backgrounds, and physical and mental disabilities;
(5) the health insurance organization or issuer’s methods for assessing the healthcare needs of the covered persons or enrollees and their satisfaction with services;
(6) the health insurance organization or issuer’s method of informing covered persons or enrollees of the plan’s services and features, including but not limited to, the plan’s grievance procedures, its process for choosing and changing providers, and its procedures for providing and approving emergency and specialty care;
(7) the health insurance organization or issuer’s system for ensuring the coordination and continuity of care for covered persons or enrollees who are referred to specialty physicians, or use ancillary services, including social services and other community resources, and for ensuring appropriate discharge planning;
(8) the health insurance organization or issuer’s process for enabling covered persons or enrollees to change primary care providers;
(9) the health insurance organization or issuer’s proposed plan for providing continuity of healthcare services in the event of contract termination between the health insurance organization or issuer and any of its participating providers, or in the event of the health insurance organization or issuer’s insolvency or other inability to continue operations. The description shall be consistent with §§ 3041 et seq. of Title 24, known as the “Bill of Rights and Responsibilities of the Patient”, and explain how covered persons or enrollees will be notified of the contract termination, or the health insurance organization or issuer’s insolvency or other cessation of operations, as the case may be, and transferred to other providers in a timely manner, and
(10) any other information required by the Commissioner to determine compliance with the provisions of this chapter.
History —Aug. 29, 2011, No. 194, added as § 26.050 on Aug. 23, 2012, No. 203, § 6, eff. 90 days after Aug. 23, 2012.