P.R. Laws tit. 26, § 9127
(a) As a condition for transacting business in Puerto Rico, employers and, except for the provisions of this chapter, those issuers offering insurance to PYMES employers shall offer all the health plans that they actively market to PYMES employers, including at least two (2) basic health plans in at least one metal level each. Issuers shall also meet the following availability requirements:
(1) A PYMES employer issuer shall issue a health plan to any eligible employer that applies for such plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health plan not inconsistent with this chapter.
(2) Unless otherwise provided by the Commissioner, the PYMES employer issuer shall not enter into one or more ceding agreements with respect to health plans delivered or issued for delivery for PYMES employers in Puerto Rico, if such arrangements would result in less than fifty percent (50%) of the insurance obligation or risk for such health plan being retained by the ceding issuer.
(b) Issuers shall file with the Commissioner the health plan forms and rates they intend to market. The issuer may begin using such forms sixty (60) days after they are filed unless the Commissioner disapproves their use. Provided, That:
(1) The Commissioner, at any time, may extend such term for not more than sixty (60) additional days.
(2) The Commissioner at any time may, after providing notice and an opportunity for a hearing, disapprove the use of a basic or standard health plan on the grounds that the plan does not meet the requirements of this chapter or the regulations thereunder.
(c) Health plans covering PYMES employers shall comply with the following provisions:
(1) A health plan shall not deny, exclude or limit benefits due to a preexisting condition in the case of an individual under the age of 19.
(2) In the case of an individual older than nineteen (19) years [of age], the issuer may deny, exclude or limit the benefits due to a preexisting condition for a maximum period of six (6) months as of the effective date of the health plan.
(3) The health plan shall not define a “preexisting condition” more broadly than a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately before the individual’s enrollment date.
(4) As of 2014, health plans shall not deny, exclude or limit benefits for a person due to a preexisting condition regardless of the person’s age.
(5) Furthermore, PYMES employer issuers shall comply with the following provisions regarding preexisting conditions:
(A) A PYMES employer issuer shall reduce the period of any preexisting condition denial, limitation, or exclusion provided that the person has had creditable coverage and that such creditable coverage ended on a date not more than ninety (90) days prior to the enrollment date of new health plan. The reduction provided in this paragraph shall be for the entirety of the creditable coverage period.
(B) An issuer that does not use preexisting condition limitations in any of its health plans may impose an affiliation period that shall not exceed sixty (60) days for new enrollees and ninety (90) days for late enrollees. Such affiliation periods shall apply uniformly without regard to any health status-related factor.
(6) PYMES employer issuers shall not impose exclusion for preexisting condition relating to pregnancy.
(7) Issuers shall permit late enrollees to enroll for coverage under the terms of the health plan during a special enrollment period if:
(A) The late enrollee was covered under a health plan at the time PYMES employer sponsored health plan was previously offered, including a health plan under the Consolidated Omnibus Budget Reconciliation Plan Act (COBRA).
(B) The other health plan of the late enrollee has been terminated as a result of loss of eligibility for coverage, including a legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment or employer contributions towards that other coverage have been terminated.
(C) The late enrollee requests enrollment in a PYMES employer sponsored health plan not later than thirty (30) days after the date termination of coverage under another plan.
If an employee requests enrollment pursuant to this clause, the PYMES employer-sponsored health plan shall be effective not later than the first calendar month after the date on which the request for enrollment was received.
(8) Issuers that provide PYMES employer-sponsored health plans shall establish a dependent special enrollment period during which the dependent and the eligible employee, if not otherwise enrolled, may be enrolled under the health plan and, in the case of the birth or adoption of a child, award of custody or guardianship, or marriage. The special enrollment period for persons who comply with the provisions of this paragraph (8) of this clause shall be a period of thirty (30) days and shall begin on the later date of:
(A) The date on which the health plan is made available for such dependent, or
(B) the date of the marriage, birth or adoption, or award of custody or guardianship.
If an eligible employee seeks to enroll a dependent during the first thirty (30) days of the dependent special enrollment period, the effective date of the health plan of the dependent shall be:
(i) in the case of marriage, the first day of the month beginning after the date on which the request for enrollment was received,
(ii) in the case of a dependent’s birth, as of the date of birth; and
(iii) in the case of a dependent’s adoption award of custody or guardianship, the date of the adoption or award.
(9) PYMES employer issuers shall not require a minimum participation level greater than:
(A) One hundred percent (100%) of eligible employees working for employers of three (3) or less employees, and
(B) seventy-five percent (75%) of eligible employees working for employers with more than four (4) employees.
In applying minimum participation requirements with respect to a PYMES employer, an issuer shall not consider employees or dependents who have creditable coverage in determining whether the applicable percentage of participation is met. Individuals covered under a health plan pursuant to continuation provisions of COBRA shall not be considered.
Issuers shall not increase any requirement for minimum employee participation or modify any requirement for minimum employer contribution applicable to a PYMES employer at any time after such employer has been accepted for the health plan.
(10)
(A) An issuer that offers a health plan shall offer the same plan to all eligible employees of such PYMES employer and their dependents. Issuers shall not offer coverage to only certain individuals or dependents in a group.
(B) PYMES employer issuers shall not place any restriction in regard to any health status-related factor on an eligible employee or dependent with respect to enrollment or plan participation.
(C) Except as permitted under this chapter, issuers shall not modify a health plan with respect to a PYMES employer or any eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage or benefits of the health plan related to specific diseases, medical conditions, or services.
(d) PYMES employer issuers shall not be required to offer health plans or accept applications in the case of the following:
(1) To a PYMES employer, if such employer is not located in the issuer’s established geographic service area.
(2) To an employee, if the employee does not live, work or reside within the issuer’s established geographic service area.
Issuers shall apply the provisions of this section uniformly to all PYMES employers, regardless of their claim experience or any health status-related factor of their eligible employees and their dependants.
(e) A PYMES employer issuer shall not be required or allowed to provide coverage to PYMES employers if, for any period of time, the Commissioner determines that the such issuer does not meet the necessary criteria or lacks the financial reserves necessary to underwrite health plans.
(1) In making such determination, the Commissioner shall take into account the following factors:
(A) The issuer’s financial condition.
(B) The issuer’s history of rating and underwriting PYMES employer groups.
(C) The issuer’s commitment to market its products fairly to all PYMES employers in Puerto Rico or in its geographic service area, as applicable.
(D) The issuer’s experience with managing risks concerning PYMES employer groups.
(E) The issuer’s financial condition will no longer support the assumption of risk from issuing health plans to PYMES employers.
(F) The issuer has failed to market its products fairly to all PYMES employers in Puerto Rico or in its geographic service area, as applicable.
(G) The issuer has failed to provide coverage to eligible PYMES employers as required in this section.
(2) In these cases, the issuer shall not offer health plans in the PYMES employer group market before the latest of the following dates:
(A) One hundred eighty (180) days after the date in which the Commissioner made the determination, or
(B) until the issuer has demonstrated to the Commissioner that it has sufficient financial reserves to underwrite health plans to PYMES employers and the Commissioner has authorized it once again to offer health plans to PYMES employers.
(f) A PYMES employer issuer shall not be required to provide coverage to PYMES employers if the issuer elects not to offer new health plans to PYMES employers in Puerto Rico. Provided, further, That:
(1) The issuer that elects not to offer new health plans to PYMES employers may be allowed to maintain its existing policies in Puerto Rico, as determined by the Commissioner.
(2) The issuer that elects not to offer new health plans to PYMES employers shall provide notice of its election to the Commissioner, who shall ban the issuer from writing new health plans in the PYMES employer market in Puerto Rico for a period of five (5) years beginning on the date the issuer ceased offering new health plans in Puerto Rico.
History —Aug. 29, 2011, No. 194, § 8.070, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 17, eff. 30 days after July 10, 2013.