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The Medicaid program in Puerto Rico differs from Medicaid programs operating in each of the 50 states and the District of Columbia in three important ways.
- The Puerto Rico Medicaid delivery system is a subset of the larger public government healthcare delivery system for most of the island’s population. The Puerto Rico Department of Health is the single state agency, and they have a cooperative agreement with the Puerto Rico Health Insurance Administration (PRHIA) also known as Administracion de Seguros Salud de Puerto Rico (ASES) which implements and administers island-wide health insurance system. Approximately half of Puerto Rico's 3.5 million residents have low incomes and depend upon the public health system for their medical care.
- Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $5.4 billion in Medicaid funding to Puerto Rico.
- Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in Puerto Rico, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing Puerto Rico’s FMAP to 57.2%.
Puerto Rico was awarded $925 million for its Medicaid program in lieu of establishing a health marketplace. Puerto Rico must exhaust its Affordable Care Act (Section 2005) allotment prior to using these funds.
Medicaid and CHIP Standard Monthly Income Eligibility Levels effective November 15, 2020 to September 30, 2021
Eligibility in Puerto Rico differs from eligibility in the states. Puerto Rico uses a local poverty level, rather than the federal poverty level (FPL), to determine eligibility. Most Medicaid eligibility and CHIP eligibility is based on Modified adjusted gross income (MAGI). The following table provides a more detailed view of Puerto Rico’s MAGI -based eligibility levels, expressed as a percentage of the Puerto Rico Poverty Level (PRPL) for Medicaid and CHIP eligibility groups:
Monthly Medicaid and CHIP Enrollment Data
As of August 2021, Puerto Rico has enrolled 1.5 million individuals in Medicaid and CHIP.
Medicaid and CHIP Applications
Medicaid and CHIP State Plan Amendments
The state Medicaid and CHIP plans spell out how each state has chosen to design its program within the broad requirements for federal funding. As always, states amend their Medicaid and CHIP state plans in order to inform CMS of programmatic and financing changes and to secure legal authority for those changes. The Affordable Care Act included many new opportunities for states to augment and improve their Medicaid and CHIP programs. As a result there has been a great deal of state plan amendment activity over the past several years in the areas of eligibility, benefits design and financing, as well as new approaches to providing health homes, long-term services and supports, and enrollment strategies like hospital presumptive eligibility. See below for a state-specific list of approved Medicaid and CHIP SPAs.
Demonstrations and Waivers
Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(a) and 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers. More information about waivers is available on the Waivers page.
- Puerto Rico elected to offer a waiver-based section 1915(a) program. It is a mandatory managed care program which requires no waiver authority because Puerto Rico is statutorily exempt from Freedom of Choice requirements.
Medicaid Delivery System
States have choices in their approach to delivery system design under the Medicaid and CHIP programs. States are increasingly moving to the use of managed care and other integrated care models in serving their Medicaid beneficiaries. Puerto Rico is 100% managed care. Beneficiaries do not have a choice of managed care plans. The beneficiaries have the option to enroll into any of the four managed care plans contracted to provide medical services island wide.
CHIP Program Information
The Children’s Health Insurance Program was established in 1997 to provide new coverage opportunities for children in families with incomes too high to qualify for Medicaid, but who cannot afford private coverage. Like Medicaid, CHIP is administered by the states, but is jointly funded by the federal government and states. States had the opportunity to design their CHIP programs as an expansion of Medicaid, as a stand-alone program or through a combined approach.
Puerto Rico has elected to operate a title XXI funded Medicaid Expansion program, and covers children up to age 19 with family income up to 266 percent of the local poverty level.