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PS 404

“Para enmendar la Sección 2 del Artículo 6 de la Ley 72-1993, conocida como “Ley de la Administración de Seguros de Salud de Puerto Rico”, a los fines de establecer un pago mínimo obligatorio equivalente a las tarifas federales de Medicaid para todos los servicios médicos cubiertos bajo este programa; fortalecer las facultades de la Administración de Seguros de Salud de Puerto Rico (ASES) en la fiscalización y cumplimiento de esta disposición; imponer sanciones a las aseguradoras que incumplan con el pago de tarifas justas; establecer un mecanismo de apelación para médicos que reciban pagos inferiores a los establecidos por la presente Ley; y para otros fines relacionados; y para otros fines relacionados.”

2025-2028 Session

Requires insurers to pay providers at least federal Medicaid rate for all covered services; expands ASES enforcement, imposes sanctions, and creates a physician appeals process.

Comisión no recomienda aprobación de la medida
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Bill Summary · PS 404

Summary of Senate Bill PS 404

Overview

PS 404 proposes amendments to Section 2, Article 6 of Law 72-1993 (the Puerto Rico Health Insurance Administration Act) to establish a mandatory minimum payment by insurers equivalent to the federal Medicaid reimbursement rate for all medical services covered under Puerto Rico’s health insurance program. The bill also aims to strengthen the Agencia de Seguros de Salud de Puerto Rico (ASES) enforcement, impose sanctions on non-compliant insurers, and create an appeals process for physicians whose payments fall below the new minimum.

Purpose and Intent

  • Establish a guaranteed, minimum payment to providers that is aligned with federal Medicaid rates for all services covered under Puerto Rico’s health insurance program.
  • Enhance ASES authority to monitor, enforce, and ensure adherence to the new payment standard.
  • Introduce sanctions for insurers that do not meet the “fair payment” requirement.
  • Create a formal mechanism for physicians to appeal underpayments under the new framework.
  • Address related regulatory and administrative matters as needed.

Key Provisions and Changes

  • Minimum payment standard: For all medical services covered by the health insurance program, insurers would be obligated to pay at least the corresponding federal Medicaid rate.
  • Regulatory enforcement: ASES would receive expanded powers to oversee, enforce, and ensure compliance with the new payment floor.
  • Sanctions: Insurers failing to meet the minimum payment obligation could face penalties (sanctions to be defined in the measure).
  • Appeals mechanism: Establishment of a process for physicians to appeal underpayments or disputes related to the new payment minimum.
  • Related provisions: The bill includes language “para otros fines relacionados” indicating potential ancillary regulatory adjustments tied to the core reform.

Who/What Is Affected

  • ASES: Expanded regulatory and enforcement responsibilities to administer and police the new payment standard.
  • Insurers: Required to adjust reimbursement practices to meet the Medicaid-rate minimum; subject to sanctions for noncompliance.
  • Physicians and medical providers: Eligible to use the new appeals mechanism for disputes over payments.
  • Patients: Indirectly affected through changes in provider reimbursement, potential impacts on access to care and service availability, and overall payment dynamics within the insured network.

Procedural and Timeline Aspects

  • Introduced: March 10, 2025.
  • Legislative actions:
    • March 10, 2025: Filed; appeared in First Reading in the Senate; referred to committees.
    • June 9, 2025: The Senate committee issued a “no recomienda aprobación” (does not recommend approval) finding.
  • Current status: The measure has not been recommended for approval by the committee, signaling potential challenges to advancement unless amended or revived.

Potential Implications

  • If enacted, the bill could raise insurer reimbursement costs to the Medicaid rate floor, potentially influencing provider payments and negotiations within Puerto Rico’s health insurance system.
  • Strengthened ASES authority and a formal appeals process may increase payer accountability and provider recourse in underpayment disputes.
  • The committee’s rejection suggests the bill may face hurdles in its path forward unless proponents address concerns or adjust provisions.

Next Steps

  • Monitor for any amendments or subsequent committee actions.
  • If revived, expect clarifications on sanctions, the exact Medicaid rate reference (federal rate calculations), and the scope of the appeals process.

Compiled from official sources — confirm details with the bill’s official record.

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