P.R. Laws tit. 26, § 9123
For purposes of this chapter:
(a) Affiliate or affiliate company.— Means any entity or person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under the same control that a specific entity or person.
(b) Geographic service area.— Means a geographic area, as constituted and delimited by the Commissioner through policy letter to such purposes, within which the issuer is authorized to provide coverage under the provisions of this chapter. The issuer shall faithfully comply with the provisions of §§ 3041 et seq. of Title 24, particularly § 3044(b) of Title 24, related to all geographic service areas in which it is authorized to provide coverage.
(c) Issuer or PYMES employer issuer.— Means any entity authorized by the Commissioner to offer health plans to eligible employees of one (1) or more PYMES employers pursuant to this chapter. For purposes of this chapter “issuer” includes an insurance company, a prepaid hospital or medical care plan, a fraternal benefit society, a health services organization, and any other entity offering and providing a health plan or health benefits subject to insurance regulation in Puerto Rico.
(d) Actuarial certification.— Means a signed statement from a member of the American Academy of Actuaries or other individual acceptable to the Commissioner that a PYMES employer issuer is in compliance with the provisions of this chapter. Such certification shall be based upon the person’s examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the issuer in establishing premium rates for applicable insurance coverage.
(e) Creditable coverage.— Means, with respect to an individual, the health benefits or coverage provided under any of the following:
(1) A health plan, whether group or individual.
(2) Part A or Part B of Title XVIII of the Social Security Act (Medicare).
(3) Title XIX of the Social Security Act (Medicare), other than coverage consisting solely of benefits under Section 1928 (the program for distribution of pediatric vaccines).
(4) Chapter 55 of Title 10, United States Code; (medical and dental care for members and certain former members of the uniformed services, and for their dependents. For purposes of Title 10, U.S.C. Chapter 55, “uniformed services” means the armed forces and the Commissioned Corps of the National Oceanic and Atmospheric Administration and of the Public Health Service).
(5) A state health benefits risk pool.
(6) A health plan offered under Chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program (FEHBP)).
(7) A public health plan, which for purposes of this chapter, means a plan established or maintained by a state, the United States government or a foreign country or any political subdivision of a state, the United States government or a foreign country that provides health insurance coverage to individuals enrolled in the plan.
(8) A health plan under Section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e)).
(9) Title XXI of the Social Security Act (State Children’s Health Insurance Program).
A period of creditable coverage shall not be counted, with respect to the enrollment of an individual who seeks coverage under a group plan, if, after such period and before the enrollment date, the individual experiences a significant break in coverage. Significant break in coverage shall be understood as a period of sixty-three (63) consecutive days during which the individual does not have any creditable coverage. A waiting period or an affiliation period shall be taken into account in determining the sixty-three (63)-day period.
(f) Eligible employee.— Means an employee who works for a PYMES employer on a full-time basis-a normal work week of thirty (30) or more hours-or on a part-time basis-a normal week of at least seventeen point five (17.5) hours-in a bona fide employer-employee relationship which has not been established for the purpose of acquiring a health plan. In this computation, those employees who are not currently working as a result of any leave or right recognized by law, such as the benefits provided by the State Insurance Fund Corporation or the Family and Medical Leave Act of 1993, shall be included. The term “eligible employee” shall not include temporary employees or independent contractors.
(g) Preexisting condition exclusion.— Means a limitation or exclusion of benefits relating to a condition based on the fact that the condition, injury, or disease was present before the enrollment date of the health plan. Genetic information shall not be treated as a condition for which a preexisting condition exclusion may be imposed in the absence of a diagnosis of the condition related to the information.
(h) Health status-related factor.— Means any of the following factors:
(1) Health status;
(2) medical condition, including both physical and mental illnesses;
(3) claims experience;
(4) receipt of healthcare services;
(5) medical history;
(6) genetic information;
(7) evidence of insurability, including conditions arising out of acts of domestic violence and participation in activities such as motorcycling, all-terrain vehicle riding, horseback riding, skiing and other similar high-risk activities, or
(8) disability.
(i) Enrollment date.— Means the first day of coverage, or if there is a waiting period, the first day of the waiting period, whichever comes first.
(j) Genetic information.— Means information about genes, gene products and inherited characteristics that may derive from the individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes.
(k) Small- and Medium-sized Businesses (PYMES) Employer.— Means a for-profit or non-profit person, firm, corporation, partnership, or association that employed at least two (2), but no more than fifty (50) eligible employees on at least fifty percent (50%) of its business days during the preceding calendar year. In determining the number of eligible employees, companies that are affiliated companies or that are eligible to file a combined tax return for purposes of taxation in Puerto Rico shall be considered one employer. After the issuance of a health plan and for the purpose of determining continued eligibility, the size of a PYMES employer shall be determined annually. As of January 1, 2016, or subject to the provisions of the regulations related to the Patient Protection and Affordable Care Act, PYMES employers shall include businesses with up to 100 employees.
(l) Waiting period.— Means the period of time that must pass before coverage for a covered person or enrollee who is otherwise eligible to enroll under the terms of a health plan can become effective. In no case the waiting period shall exceed ninety (90) days.
(m) Enrollment period.— Means a period of time established for an eligible employee to enroll in a PYMES employer-sponsored health plan.
(n) Covered person or enrollee.— Means the holder of a policy or certificate, or other individual participating in a PYMES employer-sponsored health plan.
(o) Preferred network plan.— Means a health plan under which benefits shall be provided, in whole or in part, through providers under contract with the issuer.
(p) Health plan.— Means an insurance policy, contract, or certificate provided in consideration of or in exchange for the payment of a premium, or on a pre-paid basis, through which an issuer commits to provide coverage or pay for the costs of or specified healthcare services, hospital, major medical, dental coverage, mental health services or services incidental to the rendering thereof.
(1) “Health plan” shall not include:
(A) Coverage only for accident, or disability income insurance, or any combination thereof;
(B) coverage issued as a supplement to liability insurance;
(C) liability insurance, including general liability insurance and automobile liability insurance;
(D) workers’ compensation insurance;
(E) automobile medical payment insurance;
(F) credit-only insurance;
(G) coverage for on-site medical clinics, or
(H) other similar insurance coverage under which benefits for health services are secondary or incidental to other insurance benefits.
(2) “Health plan” shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
(A) Limited scope dental or vision benefits;
(B) benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof, or
(C) other similar, limited benefits.
For purposes of this subsection, benefits shall not be considered an integral part of the plan, if they fail to meet the following requirements:
(i) Enrollees may choose not to receive coverage for such benefits, that is, the benefits provided are optional, and
(ii) enrollees are required to pay a premium or additional contribution for such optional benefit coverage.
(3) “Health plan” shall not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance:
(A) Coverage only for a specified disease or illness;
(B) hospital indemnity or other fixed indemnity insurance;
(C) medicare supplemental health insurance;
(D) coverage supplemental to the coverage provided (known as TRICARE supplemental programs), or
(E) similar supplemental coverage provided to coverage under a group health plan.
(q) Basic health plan.— Means a health plan that meets the requirements of the Essential Health Benefits Package developed according to § 9005 of this title and as defined in the regulations adopted under the provisions of the Patient Protection and Affordable Care Act.
(r) Bronze Level Health Plan, Silver Level Health Plan, Gold Level Health Plan, and Platinum Level Health Plan.— Means a basic health plan with coverage in the Bronze Level, Silver Level, Gold Level, and Platinum Level, respectively, as defined in § 9005 of this title.
(s) Group health plan.— Means a policy, contract, or certificate offered by a health insurance organization or issuer to a PYMES employer or group of PYMES employers whereby healthcare services are provided to eligible employees and their dependents.
(t) Premium.— Means all moneys paid to an issuer as a condition of receiving the benefits of a health plan for the eligible employees of PYMES employers.
(u) Producer.— Means a person who, in accordance with the Insurance Code of Puerto Rico, holds a license duly issued by the Commissioner to transact insurance in Puerto Rico.
(v) Late enrollee.— Means an eligible employee or dependent that enrolls in a PYMES employer-sponsored health plan after the initial enrollment period; Provided, That such term shall never be less than thirty (30) days.
No eligible employee or dependent shall be considered a late enrollee:
(1) If the eligible employee or dependent meets each one of the following criteria:
(A) Was covered under a creditable coverage at the time of initial enrollment;
(B) lost creditable coverage as a result of cessation of employer contribution, termination of employment or loss of eligibility, reduction in the number of work hours, involuntary termination of a creditable coverage, death of a spouse, legal separation or divorce, and
(C) requests enrollment within thirty (30) days after termination of creditable coverage or the change in conditions that gave rise to the termination of coverage.
(2) If, where provided for in the health plan, or as otherwise provided by law, the eligible employee or dependent enrolls during a specified enrollment period.
(3) If the eligible employee is employed by an employer that offers multiple health plans, and he/she elects a different health plan during the enrollment period.
(4) If a court has ordered coverage be provided for a spouse or minor or dependent child under an employe’s health plan and a request for enrollment is made within thirty (30) days after the change in status.
(5) If the individual changes status from not being an eligible employee to becoming an eligible employee and requests enrollment within thirty (30) days after the change in status.
(6) If the eligible employee or dependent had coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation provision and the coverage under that provision has been exhausted.
(7) The eligible employee meets the requirements for special enrollment pursuant to this chapter.
(w) Community adjusted rate.— Means a method used to develop rates, which spreads financial risk across the entire small group population of the issuer in accordance with the requirements in Section 5 of this Chapter [sic].
History —Aug. 29, 2011, No. 194, § 8.030, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 14, eff. 30 days after July 10, 2013.