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) › § 9175 - Guaranteed availability of individual health plans

(a) Subject to the applicable federal legislation and regulations, all issuers shall allow individuals to enroll in at least the individual basic health plans they have available in the individual market from October 1, 2013 to March 31, 2014, without risk assessment. For subsequent years, the enrollment period shall be from October 1st to December 31st of each year. In the case of health plan renewal, if the enrollee fails to renew the individual basic health plan during the enrollment period set forth in this subsection, he/she may renew it provided that such renewal is made within thirty (30) days from the due date of the enrollment period set forth herein.
(b) For health plan applications received by the issuer before December 15, the effective date of coverage shall be January 1 of the following year. After December 31, if the issuer receives an application between the 1st and 15th day of a month, coverage shall be effective on the first day of the following month. If the issuer receives an application between the 16th and the 31st day of a month, coverage shall be effective on the first day of the second month after the application was received. For purposes of this subsection, the aforementioned health plan applications are those processed within the enrollment periods set forth in subsection (a) of this section.
(c) Notwithstanding the foregoing, at any time during the year, an issuer shall offer individual basic health plans available in the individual market only to enrollees who:
(1) Exercise their conversion rights in the individual market with the same issuer that offered coverage under his/her most recent health plan.
(2) Had insurance issued by another issuer and meet the following criteria:
(A) Has been uninsured for sixty-three (63) days.
(B) His/her most recent coverage had a group health plan.
(C) Has been covered under a health plan for the past eighteen (18) months. During such time, such individual may have been covered under individual or group health plan.
(D) The most recent coverage was not terminated due to nonpayment or fraud.
(E) If the individual was eligible for coverage under the Consolidated Omnibus Budget Act of 1986 (COBRA), elected the same and exhausted it; policy letter.
(F) Lost eligibility to Mi Salud plan.
(3) Meet any other criteria provided by the Commissioner through [sic]
(d) In addition to the provisions of subsection (c) of this section, any individual whose coverage has terminated under group or individual market health plan due to bankruptcy, dissolution or revocation of the license of an issuer who issued such insurance policy shall also be eligible, provided that such individual files an application to a new issuer within sixty-three (63) days after bankruptcy, dissolution or revocation of license of the issuer is filed.
(e) The Commissioner shall establish through policy letters the procedures for enrollment periods in the event that the applicant for individual health plan elects not to enroll during the enrollment period established in subsection (a) of this section, as well as the methods to advise citizens on the terms and effects of not enrolling during such periods.
(f) Any issuer may require an applicant for group or individual health plan to fill out a medical questionnaire whereby information about preexisting conditions, as well as current prescriptions taken and care received to control a health condition, and the information of the primary care provider treating such condition. The information provided in such questionnaire shall be used solely and exclusively by the issuer for the purpose of registering the enrollee in an established program to manage diseases.
History —Aug. 29, 2011, No. 194, added as § 10.150 on July 22, 2013, No. 69, § 1, eff. 60 days after July 22, 2013.