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Medicaid & CHIP in Puerto Rico

Medicaid Overview

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 operates as a component of the island’s larger public healthcare system and is delivered entirely through managed care. The Puerto Rico Department of Health serves as the single state agency and works in cooperation with the Puerto Rico Health Insurance Administration (PRHIA), also known as Administración de Seguros de Salud de Puerto Rico (ASES), which implements and administers the island-wide health insurance system. Approximately half of Puerto Rico’s 3.2 million residents have low incomes and rely on 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 matches all Medicaid expenditures at the appropriate Federal Medical Assistance Percentage (FMAP) rate for each state, Puerto Rico operates under a different structure. In Puerto Rico, the FMAP applies only until the annual federal funding cap, known as the Medicaid ceiling, is reached, and any additional funds (such as those provided by the Affordable Care Act or subsequent Congressional supplements) are exhausted. Under the Consolidated Appropriations Act, 2023 (Public Law 117-328), signed into law on December 29, 2022, Puerto Rico’s FMAP was increased to 76% for the period from December 29, 2022, through September 30, 2027.

Medicaid-Marketplace Overview

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 April 1, 2026 to April 2027

Eligibility in Puerto Rico differs from eligibility in the states. Puerto Rico uses 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 Level (PRPL) for Medicaid and CHIP eligibility groups:

Household SizeMedicaidCHIP
Household Size 1Medicaid $1,835.00CHIP $3,604.00
Household Size 2Medicaid $2,489.00CHIP $4,887.00
Household Size 3Medicaid $3,142.00CHIP $6,170.00
Household Size 4Medicaid $3,795.00CHIP $7,453.00

Medicaid and CHIP Enrollment DataPuerto Rico Poverty

As of January 2026, Puerto Rico enrolled 1.3 million individuals in Medicaid and CHIP.

Core Set Data

CMS developed the Medicaid and Children’s Health Insurance Program (CHIP) Core Set Data Dashboard to improve accessibility of data about the quality of care provided to Medicaid and CHIP beneficiaries. CMS encourages users to explore Core Set Data to examine performance across states and to inspire and inform efforts to improve the quality of care provided to Medicaid and CHIP beneficiaries.

Starting with the 2024 Core Set, reporting of the Child Core Set and the behavioral health measures on the Adult Core Set is mandatory for states. The term “states” in this context refers to the 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. More information on mandatory Core Set reporting requirements is available in 42 CFR Parts 433, 437, and 457, and the Initial Core Set Mandatory Reporting Guidance State Health Official Letter.

The Child and Adult Core Sets assist CMS, states, and the public in understanding and monitoring access and quality of health care provided to individuals enrolled in Medicaid and CHIP. The Core Sets include measures of health care quality across the lifespan and domains of care.

CMS reports state performance on the Child and Adult Core Set measures annually. The Core Set Data Dashboard shows detailed information, including state-specific performance and national medians, on each measure that was reported by at least 25 states and met CMS’s standards for data quality for the reporting year. Data include measures reported by states and on behalf of states.

Territory Allotment