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) › § 9279 - Evidence of coverage

(a) Every limited health service organization shall issue an evidence of coverage to each one of its subscribers, which shall contain a clear and complete statement of:
(1) The limited health services to which each subscriber is entitled;
(2) any limitation of the services, kinds of services or benefits to be provided, and exclusions, including any deductible, copayment or other charges;
(3) the manner information shall be made available and where and how services may be obtained, and
(4) the method for resolving grievances.
(b) Any amendment to the evidence of coverage may be provided to the subscriber in a separate document.
(c) No evidence of coverage or amendment thereto shall be issued or delivered to any person in Puerto Rico, unless it has been previously filed with the Commissioner and approved by him/her. Each one of such filings shall be made within at least sixty (60) days prior to their issuance, delivery, or use. Once the sixty (60)-day term, from the date such filings are received in the Office of the Commissioner, elapses, the filing shall be deemed approved, unless it is expressly approved or disapproved by order of the Commissioner. The approval of an evidence of coverage by the Commissioner shall waive any waiting period left. The Commissioner may extend for not more than sixty (60) days, the period within which such evidence of coverage may be expressly approved or disapproved, providing a notice of such extension before the initial sixty (60)-day term elapses. If the Commissioner determines that the information furnished is not sufficient, or the evidence of coverage provided does not comply with any of the provisions of this chapter or the regulations thereunder and, therefore, requests additional information, the period of time from the notification of the Commissioner of such requirement to the receipt of the requested information or amendments by the Commissioner, shall not be counted for purposes of computing the aforementioned terms. To determine whether an evidence of coverage is approved or disapproved, the Commissioner may require the submittal of any relevant information that he/she may deem pertinent.
(d) If the Commissioner disapproves the filing, the Commissioner shall notify the applicant and shall specify the reasons for disapproval in the notice. The applicant shall have twenty (20) days from the date of receipt of the notice to request a hearing before the Commissioner.
(e) Any time after the applicable review period as provided in subsection (c) of this section, the Commissioner may hold a hearing to determine whether the filing meets the established requirements. The Commissioner shall provide a notice in writing to the limited health service organization that made the filing at least ten (10) days before the hearing. If, after the hearing, the Commissioner determines that the filing does not meet the requirements of this Section, he/she shall enter an order specifying the reasons for disapproval and the date, within a reasonable subsequent period, on which the filing shall be deemed to be ineffective. Such order shall not affect any agreement executed or ratified before the expiration of the term specified in the order.
History —Aug. 29, 2011, No. 194, added as § 16.090 on Aug. 23, 2012, No. 203, § 2, eff. 90 days after Aug. 23, 2012.