P.R. Laws tit. 24, § 3044
Concerning the selection of health care plans and medical and hospital health care service providers, all patients, guardians, consumers, or users of such plans and services in Puerto Rico are entitled to:
(a) An adequate and sufficient selection of healthcare plans and medical and hospital healthcare service providers to guarantee access to high-quality healthcare and services, in order for patients to be able to choose the healthcare plans and providers that best suit their needs and wishes, regardless of their socioeconomic status or their ability to pay. Patients under 19 years of age may choose the healthcare plan and those providers that best suit their needs without being discriminated against due to any preexisting medical condition or their medical history. As of 2014, the right not to be discriminated against for a preexisting medical condition or medical history shall apply to all patients, regardless of their age.
(b) A network of sufficient authorized providers to guarantee that all services covered under the plan will be accessible and available with no undue delays and within reasonable geographical proximity in relation to the homes and work places of the insured parties and beneficiaries, including access to emergency services twenty-four (24) hours a day, seven (7) days a week. All health care plans that offer health care service coverage in Puerto Rico shall allow patients to receive their primary health care services from any participating primary care service provider that the patients have chosen pursuant to the provisions contained in the health care plan.
(c) All health care plans shall allow patients to receive specialized health care services as necessary or appropriate for health maintenance within the procedures for referrals under the health care plan. This includes access to specialists qualified to render health care services to patients with special conditions or needs as to their medical or health care, in order to guarantee that insured parties and their beneficiaries shall have direct and speedy access to the providers or qualified specialists of their choice from among those in the plan’s network of providers to meet their health needs in this sense; in the event that special authorization be required under the plan for having such access to providers or qualified specialists, the plan shall guarantee an appropriate number of consultations, in order for the health needs of such insured parties and beneficiaries to be met.
(d) Select and have access to the health services and treatments by podiatrists, chiropractors, optometrists, audiologists, or naturopathic physician, if the coverage provided by their health plan offers any service that is included under the “spectrum of practice” of a licensed podiatrist, chiropractor, naturopathic physician, optometrist, audiologist and clinical psychologist authorized by the Commonwealth of Puerto Rico.
If the patient’s coverage or plan provides for compensation or reimbursement, the beneficiary and the podiatrist, chiropractor, naturopathic physician, optometrist or clinical psychologist who render the services shall be entitled to such compensation or reimbursement under equal conditions as other health professionals that provide the same services.
(e) Every public and private medical-hospital facility shall allow its patients to choose and have access to health services and treatment provided by a podiatrist, if available, and shall have the services of said provider within its staff after he/she have been evaluated by the credentials committee of said hospital, in the same manner as any other specialized doctor of the institution, without discriminating as a professional class. The requirement for the inclusion of the podiatrist into the medical faculty shall be to have completed a medical and podiatric surgery residency accredited by the Council of Podiatric Medical Education and the American Podiatric Medical Association. The clinical and surgical privileges of said Podiatrists shall be granted on the basis of education, training and expertise, as well as on individual experience, and also based on the recommendations made by the American College of Foot and Ankle Surgeons.
(f) Have healthcare plans offer them coverage without dollar limits, as defined in the federal legislation and the federal regulations thereunder, whether for lifetime, annual, or essential health benefits, as defined in Public Law 111-148, known as the “Patient Protection and Affordable Care Act”, the regulations thereunder, and the norms established by the Commissioner.
(g) Have healthcare plans include as part of their basic coverage, without any additional costs or copay, the following preventive health services: the preventive care recommended by the United States Preventive Services Task Force; the immunizations recommended by the Advisory Committee Immunization Practices of the Centers for Disease Control and Prevention; as for infants, children, and adolescents, up to 21 years of age, preventive care that includes the recommended vaccines according to their age; and, as for women, preventive care against breast cancer as recommended by the Health Resources and Services Administration. These are the minimum requirements, not to be construed to limit insurers in terms of offering greater coverage.
(h) Have healthcare plans that include dependents as part of their coverage, and to have these plans make their coverage extensive to unmarried dependents until 26 years of age. The Commissioner shall regulate these cases and their application.
(i) Have individual and group healthcare plans cover direct access gynecology and obstetrics care services without requiring referrals or previous authorization from the plan, insofar as such physician participates in the network of the healthcare providers.
(j) Have individual or group healthcare plans providing coverage for a minor as a participant or beneficiary allow the parent or tutor of the dependent minor to select a pediatrician as his/her primary care provider, insofar as such pediatrician participates in the network of healthcare providers.
(k) Have individual or group healthcare plans implement an internal claim system approved by the Commissioner that provides the adequate and reasonable procedures for the prompt settlement of disputes in connection with determinations regarding coverage and claims of insured persons. Plans shall notify their insured persons that they have access to an appeals procedure; that they are entitled to be assisted by a government official, such as the Advocate for Patients or the Ombudsman or the attorney of their choice; that they have access to their medical records; that they may present written or oral evidence; and that they are entitled to receive benefits, as determined in the process. Insured persons shall be entitled to have healthcare plans establish an appeals system before an external and independent entity that meets such requirements as established by the Commissioner. All insured persons are entitled to have an expeditious evaluation process established in case of emergency when their health is at risk.
History —Aug. 25, 2000, No. 194, § 6; Aug. 9, 2002, No. 148, § 2; Aug. 8, 2006, No. 150, § 2; Sept. 27, 2007, No. 127, § 2; Dec. 14, 2007, No. 210, § 2; June 19, 2008, No. 96, § 1; Dec. 16, 2009, No. 176, § 3; Nov. 1, 2010, No. 161, § 2.