PUERTO RICO DEPARTMENT OF HEALTH MEDICAID PROGRAM
PUERTO RICO MEDICAID STATE PLAN
MAY 2019 PUERTO RICO DEPARTMENT OF HEALTH .MEDICAID PROGRAM
PUERTO RICO MEDICAID STATE PLAN LIST OF ATTACHMENTS
MAYO 2019 ~11FFICIAL Revision: HCFA-PM-91- 4 (BPD) OMB No.: 0938- AUGUST 1991 Page 1 LIST OF ATTACHMENTS No. Title of Attachment *l.1-A· Attorney General's Certification *l.1-B Waivers under the Intergovernmental Cooperation Act 1.2-A Organization and. Function of State Agency 1.2-B · Organization and Function of Medical Assistance Unit 1.2-c Professional Medical and Supporting Staff 1.2-D Description of Staff Making Eligibility Determination 2.1-A Definiti·on of an HMO that Is Not Federally Qualified *2~2-A Groups Covered and Agencies Responsible for Eligibility Determinations *Supplement 1 - Reasonable Classifications of· Individuals under the Age of 21, 20, 19 and 18 *Supplement 2 - Definitions of Blindness and Disability (Territories only) *Supplement 3 - Method of Determinin<;J .Cost Eff.ectiveness of caring for Certain Disabled Children at Home *2.6-A Eligibility Conditions and Requirements (States onlv) *Supplement 1 - Income Eligibility Levels - Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries *Supplement 2 - Resource Levels - Categori(:ally Needy, Including Groups with Incomes Up to a Percentage of the Federal Poverty Level, Medically Needy, and Other Optional Groups *Supplement 3 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under [ Medicaid * Supplement 4 - · Section 1902(f) Methodologies for Treatment o) Income that Differ from those of the SSI Program .*Forms Provided
TN No. 11$ .. 4 MAY 1 . 1992 Supersedes Approval Date~~~~~~- Effective Date JAN 1 - 1992 TN No • f? f - I . HCFA IO: 7982E J PUERTO RICO
r.evision: HCFA-PM-91-8 (MB) OMB No.:. October 1991 Page 2
No. Title of Attachment *Supplement 5 - Section 1902(f) Methodologies for Treatment of Resources that Differ from those of the SSI Program * supplement ;ia- Methodologies for Treatment of Resources for Individuals With Incomes Up to a Percentage of the Federal Poverty Level * Supplement 6 - Standards for Optional State Supplementary Payments Supplement 7 - Income Levels for 1902(£) States - * Categorically Needy Who Are Covered under Requirements More Restrictive than SSI * supplement 8 - Resource Standards for 1902(£) States - Categorically Needy * Supplement Sa- More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act * Supplement Sb- More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act * Supplement 9 - Transfer of Resources * Supplement 10- Consideration of Medicaid Qualifying Trusts--Undue Hardship *supplement 11- Cost-Effective Methods for COBRA Groups (States and Territories) *2.6-A Eligibility Conditions and Requirements (Territories only) * Supplement 1 - _Income Eligibility Levels - Categorically Needy, Medically Needy, and Qualified Medicare Beneficiaries *Supplement 2 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not C.overed under Medicaid • *Supplement 3 - Resource Levels for Optional Groups with Incomes Up to a Percentage of the Federal Poverty Level and Medically Needy Supplement 4 - consideration of Medicaid Qualifying * Trusts--Undue Hardship Supplement 5 - More Liberal Methods of Treating Income under * Section 190l(r){2) of the Act * Supplement 6 - More Liberal Methods of Treating Resources under Section 1902(r}(2) of the Act *Forms Provided
OCT 1 4 1992 Date Ef°f ecti ve Date ------Qlll l HCFA ID: 7982E
,.. ( \ /Zw,; ~ OFFl·C-IAL Revision: HCFA-PM-91- 4 . (BPD) OMB No.: 0938- AUGUST 1.9 91 Page 3 No. Title of Attactiment *3.1-A Amount, Duration, and Scope of Medical and Remedial care and Services Provided to the categorically Needy *Supplement 1 - Case Management Services Supplement 2 - Alternative Health Care Plans for Families Covered Under Section 1925 of the Act *3.1-B Amount, Duration, and Scope of Services Provided Medically Needy Groups 3.1-C Standards and ~ethods of Assuring High Quality care 3.1-D Methods of Providing Transportation *3.1-E Standards for the Coverage of Organ Transplant Procedures 4 .11-A Standards for Institutions 4 .14-A Single Utilization Review Methods for Intermediate care Facilities 4.14-B Multiple Utilization Review Methods for Intermediate Care Facilities 4.16-A Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title v Grantees 4.17-A Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home *4.18-A Charges Imposed on Categorically Needy *4.18-B Medically Needy - Pre~ium *4.18-C Charges Imposed on Medically Needy and other optional ~roups *4.18-D Premiums Imposed on Low Income Pregnant women and Infants I *4.18-E Premiums Imposed on Qualified Disabled and Working Individuals I 4.19-A Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care
*Forms Provided
TN No. 9Jl-;p; MAY 1 Supersedes Approval Date ' 1992 Effective Date JAN ;;J - 1992 .TN No. qt)- I ----- HCFA ID: 7982E
"( PUERTO RICO
Revision: HCFA-PM-91-8 (MB) OMB No.: October 19 91 Page 4
No. Title of Attachment
4.19-B Methods and standards for Establishing Payment Rates - Other Types of Care
*supplement 1 - Methods and Standards for Establishing Payment Rates for Title XVIII Deductible/Coinsurance
4.19-C Payments for Reserved Beds 4.19-D Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services
4.19-E Timely-Claims Payment - Definition of Claim 4.20-A Conditions for Direct Payment for Physicians' and Dentists' Services
4.22-A Requirements for Third Party Liability--Identifying Liable Resources
•4.22-B Requirements for Third Party Liability--Payment of Claims *4.22-C Cost-Effective Methods for Employer-Based Group Health Plans *4.32-A Income and Eligibility Verification System Procedures: Requests to Other State Agencies *4.33-A M~thod for Issuance of Medicaid Eligibility Cards to Homeless Individuals 7.2-A Methods of Administration - Civil·Rights (Title VI)
*Forms Provided
TN No. 0.i-0 1992 Supersede~ n Approval Date OCT 1 4 199'2 Effect! ve Date ------~.UL l TN No. ,<.-,:L HCFA ID: 7982E •:.. Revision: HCFA-PM-91- 4 (BPD) OMB No. 0938- AUGUST 1991 Page l Section l STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM
State/Territory:~~P_u_e~r_t_o~_R_i_c_o~~~~~~~~~~~~~~~~~~~~~~~
Citation As a condition for receipt of Federal funds under title XIX of the Social Security Act, the 42 CFR 430.10 Department of Health (Single State Agency) submits the foliowing State plan for the medical assistance program, and hereby agrees to. ad.minister the program in accordance with the provisions of this State plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department.
TN No. 'jJ-'*7 -JAN t - 1992 Supersedes . Approval Date ~MA~~~1~_1_992~ Effective Date~~~~~~~- TN No. 7{p- q HCFA ID: 7982E . .2.· ...... -· -·...... , ... -.. ... :- .
Pl.:UI UIJJSt1 TI'I'!.3 XIX OF THE SOCIAL SECUHITYACT Attachment 1.1-A
. sta;t.e of The commonwealth JOf Puerto· :Rico . · . .. . ATTOHNEY G:SUERAL' S CD"tTIFICATl O~! t =
i c.erli.fy that:·
~ •. ..;'th<;:_~rtment of· Bea.1th of' Puerto· Rico·· is the·
' single State agency r'e spo nad.hl.e for: ·- JiIJ· admini~tcring the plan.
The local authority under wh:ich the agency administers the plan on a Statm-1ide basis is ~rt"icle· IV of the Constitution I l of the Commonwealth of Puerto Rico and Act No. Bl adopted . on Marc1!, 14, 1912, as ainended. - I { st at.ubor-y citation)
D supcrv i.s.ing the administration of the plan by local pol:i.tictl .rn.:.bdivision.s ..
The le0tl authority under which the agency supervd.scs the adrri.ni.rrt r at i.on of the plan on a Statewide basis is contnincd in I I · { st.atut.ory citation) l I ! The agency" s legal aut.hor-Lt.y to make rules and regulations • that ·arc bind in& on the political subdivisions· administ.cr• : ~g the pf.an is
(stJtutory citation) j ·~ ! l
·' .August 28, 1974 j • • • 0 ... I', • .... • ~ , •. • • • I ' • .. ~
_STATE PLAN Ut>JJER TITLE XIX ~F TIE sZ!~(CURITY l~;: . AttaC!inent 1.1-B' . . . ~. - l·!Z:>ICAL. t.ssisTA::c;: PiiOGP.A}! . ~(;.'.:-~: ·.;~:Off I Cl A [ · · State of ,_..-C""""o--._·..,... n"""p--·· .... 0-...,.?.,....1_t-h...._.;.,;n_..f_...... _,'--..P-"· ..... r ....t .. o'-"'R ..i ....c...,,.o.__ __ _..: '· ·: · . ·. . ·· .- · ·. · - · .... . ~ .. : .. WAIVER(S) OF TI-:~ SI?~2E STATE AG3i:CY REQUIP3-:ZNT GP..ArITED
-...... - . :. UNDER THE II:1'ERGOVER1~-i:ENTAL COOPERATION ACT OF 1968
·: _._ Waiv~r #1.1/ •. . . - a. Waiver was grant~d on~------..,-----~~~------~~ ... (date) b. The or-gard.zatd.onal, arrangement aut.hordzed, the nature and extent of responsibility for program administration ...' delegated to- , and '. (name o:f agency} the resources· and/or services of such agency to .be utilized in administration or the plan are described below: .
NOT APPLICABLE , '· - . . .. •!.
...... I .... · .· I ..~ -
. '. -! . . ... ". :
.. .. .
1 J.n.:or:::;;..:.i.c:;en an;/ aC.d.itior:al ~:c.:..•rers w!'.ich cave ceen grc:.ted is co:r::ai.r.,;-j ~':. at t ached s!:.ee~s.) ~· ...... ··1 . ·1FI ~ ...... ;. ._.O.Ff:JCIAL Attachment 1.1-B ... page·2
e •. The methods for coordinating responsibilities amongthe sevez-al. agencies involyed ll?. · ad."lli.'1.istration of the plan under the alternate or~anizat:i.onal arrangement· are as follows:
• NOT APPLICABLE -
. I
! . i
. .. .. , .
· o~ · m. o '·:.'':{~Vf.!- , --· .blRo/.~--/-h/-~~"_]cc c·(-:i. /.s_/'ir~.'/-~ {;,·, t.:, ;.,.rn 'fi!f0~ y . . • - . --- ':;;....:':.'"!'::=.-:::-: DFFIC\Al STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF THE SOCIAL SECURITY MEDICAL ASSISTANCE PROGRAM
STATE: COMMONWEALTH OF PUERTO RICO GENERAL EXPOSITION
GENERAL ORGANIZATION CHART
The Department of Health 1 s Organization and Operation. is I divided in two large areas, which are: I- Standards and Programatic Area: and the
II- Operational Area All advisory units belonging to the Office of the
Secretary, from ordinary Staff offices through the Auxiliary Secretaryships are included under the Standards and
Programmatic Area. The Operational Area comprises all
activities of Heal th Facilities and Med i.c aL Services
Administration and the Regional Offices of the Department. The Office of Aid to the Medically Indigent's position correlates to Standards and Programmatic Area. This office
holds a series of functional relationships with the total
Department's structure. This is possible due to the fact
that all monitoring related to the Medical As s i.e t.aric e Program
is under it's jurisdiction. Also, the functional Lrrce r-ac t i.on. -: extends to the operational level particularly on the regions.
TN # 1 :l- I I Approval Effective
Supersedes MAR 12 1993 OCT 1- 1992 TN# 79-12 Date: Date: OFFICIAL STATE PLAN UNDER TITLE XIX OF THE ATTACHMENT 1.2- A OF THE SOCIAL SECURITY Page 2 MEDICAL ASSISTANCE PROGRAM
STATE: COMMONWEALTH OF PUERTO RICO
Public Law #26 of November 13, 1975, also known as the Health
Facilities and Services Administration of Puerto Rico Act, created the Health Facilities and Servic.es Administration of
Puerto Rico. Ac.cordingly, this agency will be responsible for 7 all the operational aspects of the Department of Health. The Department of Health, in turn, will maintain the policy making functions concerning the agency's general planning,
evaluation, and auditing activities. It will, at the same time,
establish regulations for the heal th services and f aciliti.es aiming its activities to both the public and the private sectors.
aforementioned f unc t i.ons are carried on through the fourteen Advisory Off ices and eight Assistant
Secretaryships: I. Office of the Secretary of Health
A. Advisory Offices 1) Internal Auditing
2) Legal Services 3) Office of Aid to the Medically Indigent
4) Administrative Services 5) Quality Control of Health Services
6) State Health Planning and Development
7) Community Relations B} Federal Affairs Office OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF THE SOCIAL SECURITY Page 3 MEDICAL ASSISTANCE.PROGRAM
STATE: COMMONWEALTH OF PUERTO RICO
9) Women and Infant Care Program
10) Demograp~ic Office
11) Office of Profesional Standards, Regulations and
.Licence m ~ 12) Inmate Health Services ...." ...' '~ 13) Laboratory Services Institute 0 ~ U) 4> ..µ 14) OCASET ...... , rtj C'O 0 B. Assistant Secretariats 0 a1 i-:- ::a ~ .,... 1) Special Affairs > ...... , 0 u s..;· (.lJ 2) Environmental Health 0. (I- a.. c+- UJ 3) Emergency Medical Services cs::
Family Health Preventive Services
Regulation and Accreditation of Health Facilities
6) Mental Health .. _ -t• 7) Education to Health Professionals ..., t!.> -i,-, 8) Nursing Secretariarship C) U) s• The Off ice of the Secretary of Heal th consists of the (IJ a. '-'Z ::> Secretary of Health, the Under Secretary, their assistants and t- ,. V) their secretarial and clerical staff. The Secretary of Health is responsible of the overall administration of the Departament of
Health including the 1 Health Services and Faciliti.es
Administration and the Administration created for the operation of the Puerto Rico Medical Center. As an integral part of the OFflCIAt .STATE PLAN UNDER TITLE XIX ATTACHMENT 1. 2- A OF THE SOCIAL SECURITY Page 4 MEDICAL ASSISTANCE PROGRAM
STATE: COMMONWEALTH OF PUERTO RICO
office of the Secretary~ the Under Secretary participates in the direction of the De~artment 6£ Health .and in other assignments he receives from the Secretary. He also functions as Acting Secretary and coordinates the regulatory and advisory component § ..- • wi~h the operational area of the health r.egions in coordination col ~ ... 'r; and through the Executive Director of the Health Facilities and ~ C) 2 (1) (1) -J.-> Services Administration. .µ communication with the Secretary of Heal th for all official ·matters. The general functions of the advisory and assistant secretaries offices are as follows: A. Advisory 1) Internal Auditing Office ···· Performs the fiscal and operational auditing for all Department's facilities and programs to assure the most effective u~e of the resources and that the use of federal and state resources is in compliance with the applicable laws and regulations. OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1. 2- A ·OF ·THE SOCIAL SECURITY Page 5 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO 2) Legal Services Of~ice Provides the necessary .legal advise and assistance to all Department of Health and HFSA dependencies. 3) Office of Aid to the Medically indigent Si m CJ) Responsible for the administration of the Title XIX ~ I ~ -... Program in the State. ... u... ~ C) 4) Administrative Service :s 4" GI .+-> +> f1' Performs the administrative functions of the Department co Cl 0 . cl) of Health that were delegated to the Health Facilities ,-. > +). and Services Administration. :> ·- "' <.) 0 w a..'- q... 5) Quality Control of Health Services 0. f+- c UJ ~ Responsible for the establishment of s t andar ds of quality services and for the continuous evaluation of the amount and scope of medical ~er~ices. 6) State Planning and Development Office Responsible for the development of the Global Strategic Health Plan of the Commonwealth of Puer.to Rico in accordance with the federal ·and state laws. Formulates . the necessary criteria needed for the evaluation, and certificacion of the health facilities and other special projects of the Department of Health. Undertakes the necessary studies related to the areas of health services. ·OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OP THE SOCIAL SECURITY Page 6 MEDICAL ASSISTANCE PROG~AM STATE: COMMONWEALTH OP PUERTO RICO 7) Community Relations Responsible to assist the Secretary of Health in the development and maintenance the public and community relations and to provide professional assistance in the public relations field to all Department and HFSA m ' Q) dependencies. ....-N The basic activity of this office is to maintain the ~ ~ community informed about the programs and services ...... ,(!J < (tj available in the Depar~ment of Health. 0 8) Federal Affairs Office -c1' ··~ > 0 s; Advises the Secretary of Health ori federal regulations Q. .0. laws and programs funding; ~ ·g) Women and Infant Care Program Administers Public Law 95-627 as amended by section 17 of Child Nutrition Act of 1966. It provides z t- supplemental nutrition to mothers and infants at risk. V') STATE: COMMONWEALTH OF PUERTO RICO 11) Office of Profesional Standatds~ Regulations and Licence Administers State Law 11 on Registration and Continuous Education of June 23, 1976. 12) Inmate Health Services Provides institutional health services to inmates of public institutions. 13) Laboratory Services Institute Cl> Administers and regulates the operations of.clinical~ Q laboratory ~nalysi~ and blood banks 14) OCASET -Off ice of Services to. Sexually Transmitted Diseases Administers State Law 81 of June 1983, as amended for prevention and treatment of sexually transmitted diseases. It is correlated to CDC of Atlanta, Ga., the University of Puerto Rico School of Medicine and to Puerto Rico's Education Department, Social Services, Department of Services to Addiction ( DSCA),"'~" Correcti0nal Administration Department and Department z I-• v of Justice. Community groups working agaisnt drug addition, are also correlated to this office, such as CREA. This office comprise Puerto Ricots main efforts against AIDS. OFFl&IAl STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF THE SOCIAL SECURITY ~age 8 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO B. Assistant Secretariat Offices l) Special Affairs Provides assistance to the Secretary of Heal th in establishing the administrative and operational . §! policies for the Department of Heal th . and in the m -N I special programs and affairs delegated...... - 0::: ... 2) Environme~tal Health -e (.) 2 0 (1 QJ ..,_ Responsible for the planning, development, implemen- +> «:I c:" tat ion and performance of all environmental heal th Cl _...... o ~ .,..- policies in the state. Administers supervises and > + I 0 <. ~ s... (J ~ controls all sanitation activities. a. 4- O;. Cf.. 3) Emergency Medical Services cC Lt. r Responsible for the planning, organization, and opera- f ~ tion and administration of the emergency transportation \ services of the state health care system. :2 t-- 4) Family Health Preventive Services v IL Responsible for the planning, development, organization ""';;: :-'.'.:-~ a ti and supervision of the implementation and performance s, c<1 of the outpatient heal th services policy in the public ~ v: health facilities. 5) Regulation and Accreditation of Health Facilities Responsible for the implementation of the provisions of Act 101 of June 26, 1965 as amended, to license every health facility on compliance with standards and regulations. OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A . OF·. THE SOCIAL SECURITY Page 9 MEDICAL ASSISTANCE PROGRAM \ STATE:. COMMONWEALTH OF PUERTO RICO 6) Mental Health Services Responsible for the planning, development, organization and supervision of the implementation and performance of mental health c a r e and policies in the public . sector.· ·SI d> 7) Education to Health Professions ....m - N Performs the necessary functions for the planning, ... " ee ut- administration and implementation of medical and 0 . ·:::" :i QJ (lJ -}.::l paramedical training programs and other human resources .µ rd (tj Cl 0 development. (lJ ,...- > ra •r-- S) Nursing Secretariarship > +.i 0 (J s- QJ Responsible for the establishment of policies, on a. q...! c.· t,._ c:C nursing.services and to ccirrelate as advisor on nursing I matters to the Secretary's office and other pertinent rl dependencies. In addition of the aforementioned functions the advisory and z4 t-- assistant secretaries' offices provide support to the State Health System in the following areas. by delegation and in coordination with the Secreary of Health, establish programs objectives and priorities that constitute the bas~s for the Department's public policy. Establish the operational component policies in line with federal, state, and municipal regulatios. OFFICIAL·. STATE PLAN UNDER TITLE XIX· ATTACHMENT 1.2- A OF THE SOCIAL SECURITY Page 10 MEDICAL ASSISTANCE PROGRAM \ STATE: COMMONWEALTH OF PUERTO RICO Provides technical.advise through the Executive Director of the Health Facilities and Services Administration and in coordination with the under Secretary of Health. Evaluate the operational area and inform the Secretary of Heal th about accomplishments in policy implementation recommending changes in objectives in accordance wit~ I ~ actual health services needs...... c.> II. Health Facilities and Services Administration - H.F.S.A. C> (lJ ..}-> H.F.S.A. was created by Public Law #26 of November 13, 1975, cd Cl as amended. This law enables the Secretary of Health to delegate OJ > in-.:1:.he--rormnmstration, prior 'au t ho.r i.z a't.Lon by the Governor, all -r- ---"'--r:- 4--> u management and operational matters involving health· services Q) 4- 4- delivery. L1J For this end, the Administration becomes the Departmnet of Health main instrument of community accessibility to preventive, curative, and reahabilitative high quality services rendered at z l- reasonable costs. For optimum results, the law established the Administration '~·.. as an independent body with unusual maximum operational flexibility in its administrative systems, such as those relating to personnel, budget, fiscal, purchase, and supply areas. OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF THE SOCIAL SECURITY Page 11 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO In order to facilitate its performance, the H.F.S.A. has adopted the following organizational structure which was approved by the Secretary of Health in July 1978. 1. Executive Directors Office i The Professional staff of this office is the Executive I ...-c.a ... Director, the Deputy Director and their assistants. t- 'y ~ c:) The Executive Director responds to the Secretary for the :::E OJ QJ 4-3 +> (U full management, operation and services rendered by the cO 0 0 CJ Administration. The Deputy Director shares these respon- ,..- > tU •r• > +> sibilities with the Executive Director· and substitutes 0 (.) s- Q). a. t.f- him in his absence. CL (4-- < LLJ 2. Operational Managemnet Office Responsible to ·the· Executive Director fo_r the design and implementation of procedures and systems leading to z maximum bpeiational efficiency. It will also perform I- special efficiency assesments of the different components of the Department. 3. Information System The Information Systems Office consists of four basic areas of activity as follows: a. Director's Office Responsible 0£ the planning, organization, development and direction of the Integrated Info~mation System. OFFl·CIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF THE SOCIAL SECURITY Page 12 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO b , Off ice of Statistics Analysis and Control of Information Responsible for gathering, analysis and control of the statistics, computer data and 5..- development of management reports necessary for m -N .....• the different operational units. ... n:: .... -e 0 c. Cooperative Health Statistics ::E " CJ Q) ...., ....., ro Responsible to· compi1e vital statistics data 0 0 "' QI necessary for the Cooperative. National - .....> > ...., Statistics System and submit the required 0"' u CIP Q.'- 4- -c..:.~l.--::------~-=i=n=f~qrmation and reports. a...... « ..... d. Data Processing Center Responsible for the operation and supervis·ion of the Information Processing Systems (Computer and z Programming Operation). I- 4) Comptroller Area A. Office of the Comptroller Consists of the Comptroler (Assistant Director) his assistants, and a System and Financial Analysis Unit. It responds to the Executive Director for the Development of internal fiscal policies and procedures aiming to maximize income as wel:i as utilization and preservation of resoucces. OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF .THE SOCIAL SECURITY Page 13 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO It is also responsible for the design, implementation and maintenance of systems and procedures concerning fiscal policies. The Comptroller Office also· systematically ~ analyses all the financial operations of the ~ ~ -• H.F.S.A. and make s recommendations to the Executive °" ,_...... u Director: ~ 0 :a (lJ In line with the above, this office manages QJ. ..µ +> rtJ fd Cl 0 ~nd supervises the·following divisions: (l) ,...- > t'U •r- Financial, Budgeting, Accounting and Cost :> ....., 0 (.,) . s- CV Anal.sis; Billing and Property Control. a. ~ 0. llf... B. System An~lysi~ Financial Unit < LI.I Responsible for the analitical evaluation of ~ Cl) the economic resources and expenditures of the z H.F.S.A., revision of the proposed budgets and to ..._,z provide assistance to the Executive Director and to V) <11 "'O the Reg.ional Directors. Cl> fl) "'tl- • s; C. Finance Division . '. (1) z:l'5 Responsible for the accounting system at all t-:A· V> levels. Consequently, it keeps · fiscal reports necessary for adequate monitoring on the use of funds and on the financial operations of the H.F.S.A., and the Department of Health. STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF THE SOCIAL SECURITY Page 14 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF P~ERTO RICO D. Billing and Collection Division Responsible for implementation and administration of the billing function to third party payors under State Law 56, of June 21, 1969. Provides technical assistance and monitoring to the billing and m 11 en~ collections activities at regional levels. ...• ...°" I- c..> E. Budgeting Division ~ 0 :s resources for the operational H.F.S.A. It also provides assistance to the operational units of the H.F.S.A. related to the accountability and control of federal funds. OFFICIAL· STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- A OF THE SOCIAL SECURITY Page 15 MEDICAL-ASSISTANCE PROGRAM .STATE: - COMMONWEALTH OF PUERTO RICO 5) Personnel and.Human Resources Area A. Office of the A9sistant Director Responsible to the Executive Director for the operation of· the human resources and personnel functions bf the H.F.S.A. ii B. H.F.s;A. Personnel Division i - Cll ... ~ ,_ Responsible for. the H.F.S.A. personnel u ~ Ci> ~ 0) functions. Q) ..µ ~ r!'.j nj Cl C. H.F.S.A. Human Resources c I OJ ~ > _ . .J ...... , Responsible for the H.F.S.A. operation related to fU •r- \ > ~ 0 0 human resources. S- {\) 0.. q_ 0. ~ Office of Health construction and Modernization of Health - 8) Office of Purchases and Supplies { ~,·· Responsible for the acquisition of general supplies, drugs, and equipment needed by the H.F. S .A. and the Department -o f H.eal_th. OFFICIAL· STATE PLAN UNDER.TITLE XIX ATTACHMENT 1.2- B OF THE SOCIAL SECURITY MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO GENERAL EXPOSITION EC.ONOMIC. OFFICE OFllAID TO-THE MEDICALLY INDIGENT Ec.oNOM IC. The Office ofl\Aid to the Medically Indigent, correlates to the Standards and Programmatic Area of the Departmen~ of Health. This office holds a series of functional relationships with loca 1 Department structure. Thi.s is possible 'due·· to the fact that all monitoring relat~d to health, and in particular, to the Medical Assistance Program is under its jurisdiction. The Office has been established in response to the following needs of the Medical Assistance Program and the Department of Health in general. Among these are the adequate attention of the growing comple·xity of federal reports; improvement o f third party payments; continuous .follow-up upon federal legislation on health care f i nanc i.ng; to strengthen the i.rnpl eme nt a t ion of standards,· plans systems ~nd procedures; to constantly keep surveillance on possible fraud and abuses regarding the utilization of health services and facilities; to analyze fiscat ~nd managerial reports in order to :identify and evaiuate their impact and rel~vanc~~; tp keep up an active follow-up on the sources of federal, state and rQ..te. s e: ffj n 3 private funding; to moni.tor the prioo fixifig for hospital- ambulatory services; to provide an advise and monitor the TN# Approval Effective Supersedes Date: MAR 12 1993 Date: OCT .1 - 1ggz TN # 7"9-12 OFFl·CIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- B OF THE SOCIAL SECURITY Page 2 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO economic aspects on the contract negot i at i ans; to keep up an ·effective coordination with the Regions for an adequat~ Medicaid Program implementation; to be directly respons i.b Le for studies I and reports on Medicaid Quality Control. I !I Medicaid. Program operates within the Health Department 1 ! ~ Organization that· establishes eight ( 8) heal th regions. Within these regions Medicaid Program. has 88 local offices. - Advisory Committee The General Council of Health at Puerto Rico1s Department of Health, functions as the advisory committee to the Medicaid It ·was created on State Law 11 of June 23, 1976 on acc6rdance to PL-93-~41 of 1974, as ammended. The General Health Counsel is composed of 25 members represent i.ng different qeo q'r aph i.cal areas of Puerto Rico and among it's members there are health providers, consumers, financing executives, lawyers, and ex-oficio member~ from Social ~ervices D~partrnent, Education, Addiction and Stat~ Insurance Funds D~partrnents as well as the School of Medi.cine of the Univesity of Puerto Rico. 1993 Approva1 Date MAR 12 Supersedes TN ]1-/~ ... Effectiv.e Date ocr 1-· 1~ OFFICIAL ·sTATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- B OF THE SOCIAL SECURITY Page '4.. 3 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO The specific functioris of each Division under the Director of the OAMI shall be as follows: I. Medical Assistance Program Divisi.on {Title XIX) Responsible for the adm i.n s it rat ion, rnon i. tor ing and coordination, . is lan dwide of the Medicaid program thus providing ·consistent program di.recti6n in accordance with the Federal and State requi.r~ments. These functions are channeled thru the following di.visions: l. Eligibility Determination and Standards Setting Section Responsible for the development of progra~ policies and procedures; basic needs eligibility standards~ production and updating of the necesary program manuals, arid materials; and updati.ng of state plan and state program manual and other manuals pertinent to IEVS. Policy and Standards Division 1. Policy Unit: Studies the existing rules and guides, ~s well as their proceedings, and 1.S kept awareof every change coming from federal level to keep \them up to date and in -compliance 12 19~ with: TN. __ q..-...:,;i,,;;s_-__ ! ._I -----=Approval Date MAR ·OCT t-.:. 1~ Eff.~ctiv.e .Oate · OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- a O~ THE SOCIAL SECURITY Page 'S_ tr MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO a. studies the questions sent by local anual regional personnel to clarify doubts and uniform procedures. . b. keeps up to date the Program's Pol icy and Procedures manual. c , studies and keeps up to date the State Plan. d , studies and keeps up to date the federal Medicaid manuai (Parts 1-14) I EPSDT Sect.ion I Responsible for the coordination of EPSDT I I ~-.,ctivities with the Department of Social Services and ! i !1 Title V. It will be responsible for the monitoring of i ~ the program activities and f6r the provi.sion of program ! ! I evaluation and reports. I Disability Determination Board Evaluate the disabled individual~ who apply for the Program benefits because of their d i.s abi.L it y and their socio-economic poverty. MAR 12 1993 ~ 14-11 Approv11 Date. _ Supers~·d@s TN ]CJ-16 Effective Date ocr t - 1992 ' Off\&\N. STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- B OF THE SOCIAL SECURITY Page\~ MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO Validation Board Certify the Bl ind Category applicants who comply with the socio-~conomic eligibility coriditJ.on and requirements. 2. Fi.e"ld Operations Monitoring This Division is responsible of the program monitoring · operations is lanwide to provide technical assistancei assessment to the program and services administrative personnel. Plans, organizes, ·directs and .s upe r v.is es the technical aspects of the Program at regional and local levels. Advices the Regional Di.rectos of the Medicaid Program on matters pertaining the Progran and in technical and evaluation areas leading to Pz oq r am and services agreement. ,. Manta.ins continous evaluation programs training, effective administrative techniques, organization, methodology, and procedures which submits to the Program Director for approval. Coordinates Program and Information System activities with regional and local offices and participates on Program and· system 12 1993 evaluati.on comittees. lN ApprovaI Dat~AR qd---U f,L Su~!rs~dt!s TN 13-1~ Effective DateocT.i-1~m OFFIC·IAL ·•·":.··· STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- B ·:: :-'' OF THE SOCIAL SECURITY · Page '\ b MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO Partj c ipates and adv i.c e s in evaluative studies regarding quality of health servi.ces. a. Corrective Action Section coordinates and i.s c nt it establ h correct i.ve action. plans with e r e L m ~ - •• off ice staff to be implemented as pointed out by ...... " t- c:: u the Quali.ty Control System. 0 ~ ( cu .+ ....., f b. Training Section - Studies, analizes, organizes and cu c Q evaluates. training needs on ·the different Program ..- (. ••. > Areas and develop and ad~quate training program to 0'° .. S- • 0. Cf• satisfy them. 0. c: ~ c. Information System Section Coordinates Program 1 and Informat.ion System activities with ODSI, I regional and local offices. Part.i.ci.pates i.n Program system evaluation comittees. --- I ~ 3. Financial Management Statistical Division ~ ( I Responsible for the revision and approval "bf ~ 'j ::;:: provider ,_ l. claims, selection of the sample for processing purposes, revision and approval of provider cost reports, prepara't ion and submittal of federal reimbursement an ·"' STATE PLAN UNDER TITLE XIX Attachment 1.2 B OF THE SOCIAL SECURITY PAGE 7 MEDICAL ASSITANCE PROGR.r;.M STA'!'E: COMMONWEALTH OF PUERTO RICO 3. Financial Management Division Responsible for the operation and establishment of the cash management system and the capitation plan to distribute federal Title XIX funds. Reviews and approves prov~der cost reports and prepares and submits federal reimbursement and budget reports. Studies Reports and Economic Analysis Section Responsible for the analysis and evaluation of providers cost reporting system and in the production of Program periodic and annual reports. 3.1 Statistics Division Responsible for the gathering, analysis, c_ e- and reporting of all statistical data necessary for the administration of the Programs and for providing other ( required reports. •-\ ... OFFICIAL OFFICIAL· STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- B OF THE SOCIAL SECURITY Page 's, i MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO - FRAUD and Abuse Unit - Medicaid Program contracted the Department of Justice's Fraud Unit to i.nvesti.gate, determine and process fraud situations of providers, employees or eli~ibles. Hearings Boards - Processes claims and appeals r-ec.eLve d from app Li.c an ts, benef ic iar Le s and providers and submits necessary reports to the Medicaid Proqram Director. 5. Administration Division Organi~es and supervises the administrative ~pee ts of the OAMI. Coordinates ch anqes and improvements to provide necessary services. Th{s division has six sections: a. Personnel Section - Responsible of the coordination ~nd supervision of the administrative procedures related with the human resources and pe r sorme L; functions of the Program. 12 1993 TN qi-U Approva1 D~te MAR · Supersedes TN Jq-1 J., Effect 1 ve · D.ate ocr · 1 - 19i ·oFFl·CIAl STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- B OF THE SOCIAL SECURITY Page 'l_..Q 'f MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO b. Administrative Budget Section - Designs the i.nternal and external work plan for the OAMI including the plan for eva 1 uat i.on on program operations, investigations and necessary studies for the establishment and revision of pol i.c i.es concerning the administration of the Program. c. Purchases Section - Responsibl~ for the adquisition of general supplies and the equipment needed by the OAMI. Coordinates and supervises the supply of the .u.:»: equipment and the materials requested. -==---- l) d. Maintenance Section Responsible for building maintenance. e. Inventory and Warehouse Section Keeps complete stock and control of required mater i.als in accordance with the Department of Health rules and regulations. f. Transportation Section - Responsible for providing transportation services and upkeeping the official vehicles. TN 2~-ll Approval Date MAR 1 2 1993 TN Effective. Dateecr 1 - 1992 Supersedes. . --... ~ ]9-[$. --- OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2~ B OF THE SOCIAL SECURITY Page ".H.- IO MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO 6~ Quality Control Division Quality Control is a systemati.c and coordinated effort by State and Federal Government to assure proper and efficient administration bf Medicaid. The primary purpose of the System i.s to supply State and Federal administration with information concerning correctness of eligibility determinations and payments amounts. The Quality Control System is designed to measure error rate levels and to provide information on the nature =e> causes of errors so that corrective act ions may be undertaken. The objectives of the Medicaid Eligibi.li.ty Q.C. System are ac~omplished by means 6f a continuous review of recipients identified through statistically reliable samples. State Q.C., reviewers make full investigation,r carry out face to face interviews make full investigation, carry out face to face interviews with the recipi:ents involved and verify and document each element of eligibility. 12 1993 TN q IX -II Approva 1 Date MAR · OCT t - b Superse-.de.s TN Effective Oat~ 19 OFFICIAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1.2- B OF THE SOCIAL SECURITY Page ~II MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO The Divi.sion of Qual i, ty. Control is centralized. The development of ~his activity on the regional level is performed by social service technicians (Q.C. reviewers) supervised by the Central level. Director The Director of the System performs his job under general guidance and direction 6f the Director of the Medicaid Program. Is responsible for the direction of the Quality Control System, providing constant supervision of personnel and to all activities within the System; planning and ____J___:- establishing the scope and priori ties of these. c::::::--u-:ose coordination with the Agency's statistical staff, other administrative and normative staff within Program and other Staie Agencies. Assures to maintain the' Program. informed· about the review findings and cases in error so that corrective action may be undertaken. Maintains an adequate staffed organization in order to keep all the required activities current and at a maxi.mum guali.ty level. { \ TN 1 J ~ l/ ApprovaI OateMAR 12 1993 Supersedes TN ]9-I?> Effective Date ocr 1 .. 199i . OFFIC-IAL STATE PLAN UNDER TITLE XIX ATTACHMENT 1. 2~ B -,-··· OF THE SOCIAL SECURITY Page~ I~ f--- \ MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO Quality Cont~ol Reviewers goes over the cases included in the monthly samples. The work of these reviewers consists the revision of the eligibility determi.natjon of the sample cases certified eligible by the Medi.ca.id Program. They will cover the revi.sion of sample cases certified eligible as well as negative cases. Included also is a review of Ineligile AFDS and AABD cases recei v i.riq cash ass.i stance to determine el.i.g ibl.i ty for Medic a i.d , As part of their duties, they wi 11 determine and identify the existence of Thi~d Party b Liability resources, and will perform the Claims Process.in~ Q.C. Review. The Qual{ty Control reviewers are located i. n accordance to the Program's regional offices. Central Office Quality Control staff keeps track of all completed sample cases of recipients certifi~d eligible by Medicaid Program, and all Q.C. AFDC. and AABD cases and edit the eligible sample ca~es, TN qJ-11 Approval Datct!AR 12 1993 (()CT l - 199'2 Supersedes TN New Effe.ctive Date _ OfflCIAl STATE PLAN UNDER TITLE XIX ATTACHMENT 1. 2- B OF THE SOCIAL SECURITY Page -r-4- 13 MEDICAL ASSISTANCE PROGRAM STATE: COMMONWEALTH OF PUERTO RICO performs the TPL review and the computations of misspent dollars of all cases in error including the AFDC and AABD cases. Desk reviews for all i.nel i.g ib le cases of th 1:s sample, are conducted for assignment to the regional reviewers for field .investigation. Quality Control Program Division wi 11 coordinate efectively with Fraud and Abuse Unit in order to adequately refer those·situations that through their field investigations and/or desk reviews a possible fraud situation is suspected. TN. qg-l{ Approva1·oateMAR i 2 1993 . OCT . 1- 1992 Supers.edes TN New Effective Date h State: Commonwealth of Puerto Rico Of fl GI Al OVERALL INTERACTION OF THE FUNCTIONS ·AND ORGANIZATION OF THE MEDICAL ASSISTANCE ':R As an answer to existing agreements among the Federal;, the Commonwealth of Puerto Rico it is deemed necessary, as part·?~• Ass i stance State Pl an, to present the various internal and exter'" ships of the Department in accordance with such agreements. Oia~J'.$ illustrates such relationships with the Social Services Departmer:i~{ ;,1.···· Secretaryship of Ambulatory Services (Family and Health Planning)·a . .,., .· ~- Aux i 1 i a Office of the of ry Secretaryships; the Director Certificatid.,..;· Licenses; the Information System Office as we11 as the Office of Hea Besides, the diagram shows at the level of the Health Secretary the.\: ... :~'• .: ~::.-; Advisory Committees, one for the Medical Assistance and another specf EPSDT. Through this organization the responsibilities Department, as the single State Agency are delineated. ' - co11xo::.:r;,\LTll OFFICIAL OFFICE OF ECONOMIC Al~ ORGANIZJ ------;f ~t~f"'v I S!::CRETARY U,l/lf()J//llt~ I ~ 1""~/r..J: SUB-SECRETAI I 14ri;- .1 IH"r::Tl1M TT OFFICE OF E TO HEDICAbL MEDICAL A DEPARTMENT OF PRO( SOCIAL SERVICES!:/_ f I ..... l FINA.NC IA L AND COORDINATION OFFICE OPERATION DIVISION ....-- STATISTICS DIVISION - FOR PRO-FAT CORRECTIVE ACTION AND STATISTICS SECTION - TRAINING SECTION - ., FINANCIAL S ECTION ,....__ INFORMATION SYSTEM - SECTION ·I DOCUHE~ff REVISION SECTION 1) General Health Council 2) A Committee appointed by the Program Director comp_osed by the Division's supervisors, prepares corrective action plans based on Quality Control findings. Analizes, studies and answers to consults submitted by Regional Directors, Department of Health's officials or any other agency. · 3) The Social Services Department coordinates the Income Elegibility Verification System for the Commonwealth Agencies in compliance with OBRA 1986. 12 1900 TN 9 '6-11 Approva·t Date MAR . oc1.1-1~ Supers:ede~_TN 1q-1~~ Effectiv·e Date _ "PUERTO RICO TllE MEDICAL.LY INOI(;E:;r DIAGRAM II OFFJ~C·IAL )N CHART r~ r--····-···- -· ... -- ...... HEALTH ADVISORY co:-~tITTEY JF HEALTH I I 'OMlC AID - _;__'··_ - J NDIGE~TS STA~.:CE. l. _1.1_/_•·· l I I I POLICY STANDARDS & QUALITY CONTROL SYSTEM ~ ADMINISTRATION DIVISION - DIVISION .. 1.1"1'''-....,,, r'f-~ ,.. ·• . - - .. I DISABILITY DETERMINATION ... .--- PERSONEL SECTIO~I .. -~ - BOARD I .. . COORDINATION ADMINISTRATIVE - IEVS - SECTION : - BUDGET SECTION EPSDT-COORDINATION ....-- PURCHASES SECTION :- SECTION ~ ~ / / ~- ·~ Agne=sGUZffia~ ,__ D MAINTEN •.\..~ CE SECTION '~~ -- ' - INVENTORY AND WAREHOUSE ~ ~rrdenJvJ~e~~~m ~ SECTION Jose E~Soler Zapata, M.D. t I I i. ) l TRANSPORT~ T_I_o_N_s_E_c_r_r_o_N_ 2 19ta TN IP 1i-JJ. .Approva 1 Date MAR· 1 S ttpe~s.ed e.s TN 7q_)J ~f-Ft\r.f. .;u,.. ·n ... .a..- O'CT ·.1- 1992 ladminlatei:s the Dep1u:tment. o.t H~nlth which S'l"Pl'fB Hl.::Dlc,\L CALlE li.DVISOR;.~ ii tha t1ingl0: llt 1 tllfVN""'flOH S'l&rfl-C DI!eCJ'OJl, orric:e: 01'·PLNiHlUG, IWALIJATJON', DIRECTOJl. H!.DlCAL ASSIS.'l'iiM~ il\'llc:orl!lt,,9 to thq i;i•tablbhdd l\9C"aa111nt1 .POLlCIBS, AlhJ ECOHOHIC MfALYBI8 l'l\M1Wt l!C'rrLS XDC) l..;rl11.ns,01;"9an i. D•v•l l". Si.ip.,cvh•• tho S""eYial1>111 arid 11noly.S.1 l. Direct• and it\.l?ll:Vl•iu t:J..1e ie:.rt.ify:lng ~lON>L HOSeITM& ll••BCI>MIZBD ~n·r~~I ~- noslpITALS L -;" ~vTaRS .PtJBLICNeALT'fl WITS\ Qf Re11icn1l prc'lidor:1 cl11.i_,. 2: A'11Dtsthe E11:aeutlva D.h:cr:tor in· ll.ttO< validGting b!tcht:1.ic.t1.l activities roqardlnlJ n.,ppllcant•~ ;,,&:!inh1r;ra.tivlll a•,pac:ic.1 of th1111 l'rcqe"&.111. :Z • P.11.J""tic:lp!!te11 in t:he d1welop:1ent and SOC'IJ\i. SERVICE Tt:=mrICIJ\M .• wcr.r. LEV6& 3. P::ap.u:cs tho •tati::1t.h:1l z:eport.s re.q11¢•t~n ht th!!> ProJ:-on. oi: by UJ~ i:apliemeintation of the 'Wtlrkplan ..pC"•• 1. Coordinateg. wit:h the. D;ket:to~ of the £: - H..EOlCM. J,.SSIS'I'l!.llCIS J\lDE 1. ~Saiat tho Social Service T~cbn·~t•n in t11a intn.rviow andi o:rJ..entetj.C>n ra~~~~:s ~ocial Socurity numbor a;pli~ DISit.Btt.l!E'Y DMJtlUUlt1'11lOlf 1------ I ASSJ:'!. 6ECR. AMBIJU\:rQRY06.RVltES I r-~~~!~M ASSIST. SECRRVIJ\YFOR PlaNININa ASS.IS'?. sacne, PUBLIC r.ra&Pl.1vs Plana, Q11i'9'•nb:H, di-i:ei:ot.J, and · :.· ~.rvic .. to tb ~t11Uu thll b:iplm•ntat:J.onol : :t.ragr .. .ln polidc:i. an4 opt.ration• r4ittu.~dl~g ptHCMll, _. b\.1314n wt:-~tbnh .arvlc-H Eond~1111d. by tha r>ap:actnent:. of ~•at.th.. -·r:!;:::..i ll'l~li~y. -·the- •t0fl'l:U1 • _;1-,...i._. _ __,:__ _:._. ------'-- . ::;~::~::4 · 1! · 1:port.a to the· n~Ony ofHe1·. :n fAMlLY. JtEAI,TH: DIVl8IOl'f r COMMONWEAl.}I OF PUERTO RICO DEPARTMENT OF HEALTH MEDICAL ASSISTANCE PROGRAM FUNCTIONAL ORGANIZATION APPROVED .,._,;~gb /SECRETARY OF HEAL'Nt JANUARY J, 1979 ERVISSION TJONAL RELATION DINATION AND ASSESMENT I I l I ATTACHMENT 1.2- C STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: COMMONWEALTH OF PUERTO RICO DEPARTMENT OF HEALTH OF PUERTO RICO MEDICAL ASSISTANCE PROGRAM Professional Medical and Supporting Staff for Title XIX: Jaime Rivera DueRo5 M.D. Secretary of Health Heriberto Morales~ M.D. Under Secretary of Health Julio Cesar Galarce Director Office of Health Economy Irma Revilla de Ferrer Director, Medical Assistance Program Executive Director II (Vacancy) Fiel Supervisor Monitoring Program Physician IV (Part Time) - Vacancy APTD Medical Consultant Zoe Suarez (Social Worker) APTD Social Consultant Ramon Feliciano Statistics and Information System Hector D. Maysonet Cardona Accounting and Fiscal Management Vacancy Certification Standards and Policies Francisco Olivo Administrative and Personnel Officer Gloria Vazquez E.P.S.D.T. Coordinator Victor P. Santiago Planning and Management Systems Consultant Department of Health Staff Acting as Consultants for Title XIX: Luis S. Miranda, M.D. Planning and Developm~nt and Licensure and Certification of Health Facilities and Services Jose E. Belardo Robles, M.D. Ambulatory Services Manuel Andrades, Architect Health Facilities Francisco Hernandez Oquendo, M.D. Oral Hygiene Aida Guzman, M.D. Mental Health Antonio Hernandez Torres, M.D. Environmental Health Blanca Rivera (Attorney) Legal Services ~ Jose Camacho Administration and Health Manpowe~ Efra1n Rodrfguez Vigil, M.D. Institutional Services Emilia Hoyos Rucabado, B.S.P.H. Pharmacy Consultant o . . [ q ('60 . ' '7 //}I' l ST·~~P SA Approvedl._ j _RO Apprwed.i.J.d§./30 Eft~ouve I I; /[D. ATTACHMENT 2.1-A Page 1 COMMONWEALTH OF PUERTO RICO STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MANAGED HEALTH CARE STATE PLAN DEFINED HMO The Puerto Rico Health Insurance Administration (PRHIA) was created by Commonwealth Law Number 72 effective September 7, 1993. PRHIA is a public corporation. with full autonomy. It is responsible for implementing, administering and negotiating a health insurance system, through contracts with insurance underwriters that will eventually give all Island residents access to quality medical and hospital care, regardless of their financial condition and capacity to pay. PRHIA has an agreement with the single State Medicaid Agency. to carry out the provisions of Law Number 72. The.Singl~ State Medicaid Agency is the · Department of Health. Within the Department, the Of'f Lc e of Economic Aid to. the Medically Indigent has responsibility· for the Medicaid Program. PRHIA enters into risk contracts with entities/insurers organized under Commonwealth Law 152 (approved on May 9, 1942) to provide or arrange for comprehensive heal th care services. These consist of Basic Coverage a0d Special Coverage as detailed in the contract. PRHIA contracts health insurance for one or more areas or regions, with ~ne or more entities/insurers licensed to do health insurance business n Puerto Rico. Services are rendered following the regi6n~lization· ~.rstem of the Department of Health, progressively establishing a newtwork of participating purveyors throughout the Island. Within.each region Primary Care Centers will be established. These must be staffed with consideration to the morbidity and mortality rates of the specific health area and must be sufficiently staffed to provide all the benefits included in the Plan. The entity/insurer must demonstrate to PRHIA the adequacy of its provider network in relation to the region or health area it will serve. Services will be as accessible to Medicaid enrollees as they are to non-enrolled Medicaid beneficiaries. The entity/insurer must demonstrate financial soundness according to Commonweal th statute, e t c , , and must submit financial and other reports to the Administration as specified in the contract. ;r the entity or insurer is de~lared insolvent, files for bankruptcy, or is placed under liquidation, the · Administration has the option to cancel and inmmediately terminate the contract. In the event that the entity o~ insurer is declared insolvent, files for bankruptcy, or is placed under liquidation, Medicaid enrollees will not be liable for it.s debts, 'J1he errt l ty/insurer must guarantee 't.o the Administration that the premium constitutes payment· in full for the benefits under the program and that participating providers and/or their subcontractors cannot collect any additional amount from the beneficiaries. · TN q 4:-/ Approval Date APR l 9 1994 7)Uperse~} .: .·N No. wew Effective Date JAN 1 - 1994 OFFl&tAL HCFA-PM-91- 4 (BPD} ATTACHM.ENT ·2.2-A . Aut;usT 1991 Page 1 OMB No. 1 0·939- STATE PLAN UNDER TITLE XIX OF THE ~OCIAL SECURITY ACT .. ·.:.. ~. ~ ~··· .. · . : ... ·. ·. : .. ·. Territory: Puerto Rico ·~·:::. :: .: ;:: · .. ·: -: · . : .. · .. • . ·GR~UPS cov.ERED AND . AGENCIES RESPONSIBLE FOR ELIGIBILITY ·DETERMINATION qitation(~) Groups Covered .:.· . . . : T~e ·following gro.ups are covered urider this plan. A. Mandatory Coverage - ··Categorically Needy 42 CFR 436.110 1. All recipients-of OAA, AB, APTD, AABD, ,;.>·:,:'.;:·d·~·:;1:·::~'t. ·, ::.. : : .. .. . this includes ail individuals '(ho are ·eaae"rit'11lJ. :~·:~ ·:::·:.. ~.·~~·:.-· ·persons under the State plan and.who.could be recipients if the. atate plan as .~.\ ~: ~ ·.:\~;.:.·. :·~·:·~r·~ J ~ ~: .: •• : .: ·.· ·.·oss were broad as permitted for Ff)deral finaiicJ.al _p~rtlcipation. Also :;::. ".:· :.):~}-.::}.··~-· / .... ·, .. focluded·ara·gr.oups checked pelow which·ara covered .... under. t·he ·approved stat.a pl.1m for. flnancial assistance. ,··· ...... Tbe standards'fo~ OAA~ A.a;·APTD, M.~D arid ... . , . payments are listed in SuPP·lemen~· 1 of A'l''fACHMENT" 2, 6'-A ,' -. · The definitions of blindness l~ ~erms of ophthalm~c me·asurement and of permanent and total. disability used ln this plan are sp·ecified in supplement· 2 to '• .. · ATTACHMENT 2.2-A. ... ·:··: TN No. Effec·t1ve· natftlAN 1 . Supersed Approval Date MAY 1 1992 - .1992 TN No. HCFA ID: 7984E~ ' ' Transmittal No: 13-006 Effective Date: 01 /01/2014 Partial Supersedes; Approval Date: 12/24/2014 Transmittal No: 92-2 <; OFFICIAL. Revision: HCFA-PM-91-4 {BPD) "ATTACHl,fENT 2.2-A r::~'.::11 ··.''';.;'. AUGUST 1991 Page 3 . ~~:;1~:·~~~r;; \.~:·~,. · .· -: ;.::,· :· OMB No.: 0938- . ·. Terr! tory: Bjco f~ ··········-~. ·. ', ::: -, ·. . ... :. . Puerto \ Agency• Ci tation('s) Groups Covered A. Mandatory Covera9e Cat·egorically Needy (Contlnued) 42 ··cFR. 436 .112 3~ ·tnaividuals who would be eligible fo:r; OAA, AB, APTD, AABD, .· ;'·'except for the increase in OASDI berieff~C1er ··P.L. · 92...:335 (J"11Y 1, 1972), who .were entitled ·to OASDI in August 1972, and who ·were · · 'DSS. ·. receiving OAA; AB, AP'l1D, in August· 1972. Includes persons who wQuld have been eligible ·.for cash assistance but ·had not applied Ln. August· 1972 (this group ··was included in ·thia · Stat~• a Augu~t 1972 plan).. · · · x Includes persons who would· have bEien .el.iqlble . . for cash .assistance in, August ·1972 if not .Ln a I•':: medical institution or inte·rmediate car~ ••• ,.:···. e: .• fac"ility (this group was includetd in ·this State's August 1972 p~an). · x ~-~i¥~i::> ( ' .Not,appi°!cable with respect to intermediate · .. · care·facilities; the. State did or does not . . . . : .covar this service·. : .. ;: ·.·,.· .. · .. ·. ~ \ •, • , I• ': •• :, ' ': • . ~ :. . . ~ ... ,• . .,. r. : . :· . . ,: /0 =TN_,..N-o-.~-2~~~-~;:;:>--~--~~----.QA'l"ft"l~~l.-~1~992'."""-~------~------~--·--. Superaedesn.H / "". Approval Date ----- Effective Date JAN 1- 199 TN No, tJ...... L- . HCFA ID: 7984E.;... Transmittal No: 13-006 Effective Date: 01/01/2014 .. Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 l t OFF·IC·IAL Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.2-A AUGUST 1991 Page· 4 ·-:.· OMB 'No.: 0938- Territory: Puerto Rico Agency• Citation(s) Groups Covered A. Mandatory Coverage - Categorically· Needy (Continued)'. 402(a) (22) {A) ·DSS of the Act . . ~ 406(h) and d. An assistance unit deemed to He r_eceiving · 1902(a) (10) (A) AFDC for a·period of four calendar months (i)(I) ~f the Act because the family becomes ineligible for AFDC as·a result·of collection or increased collection of sup~ort and meets t)le · req~irements·of sectiqn 406(h) of'the Act.· 1902(a) of the e. Individuals deemed to be recelving·A~DC Act ·who meet the requirements of section 4 '13 (b) ( 1) or ( 2 ). for whom an adoption .assistance agreement is in effect or foster care ·.maintenance payments are be Lnq made under title IV-E: of the, .Act •. D S S 4 0 7 ( b ) , 19 0'2 ( a ) (lO)(A)(i) and: 1905(m) (1) of the .Act 42 CFR 5 • Families terminated from AFDC solely because of . 436 .116 .Lnczeaaed earnings or hours of employment, ·provided -the family ,received AFDC in at leas·t three.months du~!ng the six-month period. immediately preced!ng·tne month·in which ineligibility began and provided 'that one member · of the family is employed throughout· the period · specifi~d in the next sentence. Med!9aid is provided.· for four calendar months beginning with· .. the month AFDC is terminated or,· Lf AFDC.is terminated ret:roactively,. ·with· the fi_rst month in which AFDC was erroneously paid. Approval Date MAY 1 1992 Effective Date ·JAN 1 - 1992 HCFA ID: 79B4E '*· Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 Revision: HCFA-PM-92 -1 (MB) ATTACHMENT 2.2-A ~EBRU4R~ 1992 Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OFFIC·IAL Territory: PUERTO RICO COVERAGE AND CONDITIONS OF ELIGIBILITY Cita'l;:ion ( s) Groups Covered 1902(e) (5) 7. A woman who, while pregnant, was eligible and of the Act applied for, and receives Medicaid under the approved State plan.on the day her pregnancy ends. The woman continues to be eligible, as though she we~e_pr~gnant, for all pregnancy-related and postpartum medical assistance for a 60-day period (beginning on the.last day of-pregnancy) and for any remaining days in the month in which the 60th day falls. •-.~... ·. . • ,; •• e ' • . ·, ...... t ·· { TN No. 9~- q: - fJCT 8 1992 Supersedes Approval Date - Effe.ctive Date JUL l- 199'4J TN No. j a-?- , , ,..,...'"!-~· .. •--1t:.....-;·.,.w;:~·T'°'~~~~-:~ •'t't ..·r~,..,.. :--·- .. ""' • · • --1• _."',.,.. ... -•· - ,.,.: ...... - ••. .- • ·•'l•1•o•r.•• ••" ••·•·•-•:••:::.~'""-' • •• ;···· '" - - .. ,_,,,._. . ----·· . . ~-:~ .. : . :: . (~ :- . • · .. +»:> Revision: BCFA-PM-92-1 (MS) ·FEBRUARY 1992 STATE PtAN UNDER TITLE XIX OF 'l'BE SOCIAL (--·- Territocy: · PUERTO RICO' COVERAGE AND CONDITIONS OF ELIGIBILITY ·citation(s) Groups Covered .A. Mandatory Coverage - Categorically· Needy (Continued) ·1-902 ( e) (.4-) 8. A child· born to a woman who is eligible. for and of the Act rece'ivihg Medicaid on the date of the child's · birth. The child is deeme4.eligible for one year :from_bift~ as ·long as the mother remains eligible or would have r~ained eligible if still pregnant and.the child remains.in the same household .as · the mother. . . . . 1902(e)·(6) 9. . ·A pregnant woman 'who woµld otherwise lose eligibility during the pregnancy or· the ·. · postpartum ·period because of an increase ··in 1 . incom'." · ~;Hi~;~!~:·· B. ·Optional.Groups· Other Than.the Medically NeedY- 42 CFR 436.210 :X -1. Indtvidµ~is· ~ascribe'~ below who meet the ipcome . and .resourt:e requirements of OAA, AB, APTD ,· · AABD, };),ut ;Who do not receive .cash , assistance. x ·The State covers all individuals' as ·despribed. above. The State covers only the.foliow~q group or groups of individuals: 1902{a:)(10) Aged (A)(ii) and . Blind. 1905(a) of Disabled the Act Caretaker relatives Pregnant· ·women 42 CFR 43.6.211 -1L 2. Individuals who would be eligible for OAA, AB, ·=· _,, APTD1 AABD . ·'if they were not in a. medical insc.i-cutl.bn. X The State covers all individuals as described above. J Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-4 / \ ... TN No. qa-'f Supersedes Approval Date t)CT ~ 1992 Effective Date JUL l- 19l2J TN No. . 't:l-a .. • •··-- ..... • • • • • ...... _ '"'""'·•---~·:.;·- ...: -r:.~~~,,_,.,,,..,~,,...... : ..... '•'"!i<:'"'''••:~: :·-~- .. ~.., .... ,.,.,.,..,,.: ••••••••:•.u·~-o ..~ .... ,: • ••• ,,:_,, ... ,.,...,_,,..., , , ,. .. ,.~.,.., ... _ ... _..., __ :••e.:•r,.,...... -r~•- ...... ---•..- ... - .. ':· - .. : -, .~ .. . •... Uff\&\~l . {BPD) .· ATTACHME~ 2."2-A Paqe e· OMB No.: 0938- · Te:tritory: Puerto Rico· Citation{s) Gr9ups· Covered B. ·optional Groups Other·tban Medically Needy (Continued)· • . I • • • ' 3. ··Indiv.t~ ~hi;) would be eligible for OAA, AB, APTD, AABD,1. . !'f coverage ~nder the State's plan for these'pr~s ware· n.a'broad· as parmitted·undar th.a Act: . ·Individuals meeting a broader definition of .. permanent and .total d~~abili.ty. ·. Individuals meetih9' a· ·broader definition of blindness. · Others, as ·-~pacified below:· I ! ...... . ·, .. "('" . ,.. :, • : ~· ~ .:. 1'= •: . ~. I :·-:... I . '. .. .. v TN No, -90?-C:Z Effective Date JAN J. - 19gz supersedes S?- / , Approval D~te'M,"'l\._~_1 _1_992_. TN No.• HCFA IDi 7984E..,.. Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 ! Revision: HCFA-PM-91-4 AUGUST (BPD) ATTACHMENT 2.2-A 1991 Page 9 OMB No.: 0938- Territory: Puerto Rico Agency* Citation(s) Groups Covered B. Optional Groups Other than Medically Needy JContinued) 1902(e) (2) LI 4. The State deems as eligible those individuals of the Act, who become otherwise ineligible for Medicaid P .L. 99-272 whi l'e enrolled in an HMO qualified under title (sec. 9517} XIII of the Public Health service Act or while and P.L. enrolled in an entity described in sections 100-203 1903(m){2)(B)(iH), (E), or (G) or section (Sec. 4113(d)) 1903(m}{6) of the Act., but who have been enrolled in the HMO or entity for less than the minimum 'enrollment period listed below. The HMO or entity must have a risk contract as specified in 42 CFR 434.20(a). Coverage under this section is limited to HMO services and family planning services described i~ section 1905(a)(4){C) of the Act. The minimum enrollment period is (not to exceed six months). The State measures the minimum enrollment period from: LI The date beginning the period of enrollment in the HMO or other entity, without any intervening disenrollment, regardless of Medicaid eligibility. LI The date beginning the period-of enrollment .in the HMO as a Medicaid.patient (including periods when payment is made under this section), without any intervening disenrollment. ~ 1 199'l Approval Date M~~~~~~- Effective Data.JAN l- 1992 HCFA ID: 7984E ,;,,,. OfflCIAl Revision: HCFA-PM--91-10 (MB) ATTACHMENT 2.2-A DECEMBER 199,1 Page 9a State/Territory: ~~~~~~~~~~~~~~~~~~~~Puerto Rico Agency* Citation(s) Groups Covered 1634(d) of the A. Mandatory Coverage - Categorically Needy and Other Act Required Special Groups (Continued} 24 •. Disabled widows, disabled widowers, and disabled unmarried divorced spouses who had been married to the insured individual for a period of at least ten years before the divorce became effective, who have attained the age of 50, who are receiving title II.payments, and who because of the receipt of. title II income lost eligibility for SSI or SSP which they received in the month prior to the month in which they began to·receive title II payments, who would be eligible for SSI .or SSP if the amount of the title II benefit were not counted as income, and who are not entitled to Medica~e Part A. The State applies more restrictive eligibility requirements for its blind or disabled than those of ,the ssr program •. In determining eligibility as categorically needy, the State disregards the amount of the title II benefits identified in§ 1634(d)(l)(A) in determining the income of the individual·, but does not disrega.rd any more of this income than would reduce the individual'~ income to the SSI income standard. In determining eligibility as categorically needy, the State disregard only part· of the amount of the benefits identified in §1634(d) (1) (A) in determining the income of the individua which amount would not reduce the individual's income below the·ssI incom standard. The amount of these benefits 1 to disregarded is specified in supplemen: 4 to Attachment 2.6-A. In determining eligibility as categorically needy, the Stat~ chooses not to deduct· any of the benerit .. identified in § 1634(d) (1) (A) in.' determining the income of the individual Not Applicable *Agency that determines e+igibility for coverage. TN No. Superse Approva-1 DateOCT 14 199Z Effective DattfLJL 1 TN No. 1992 Revision: HCFA-PM-91~10 (BPD) Attachment 2.2-A DECEMBER 1991 Page IO State: [Puerto Rico] Agency* Citation(s) Groups Covered B. Optional Groups Other Than the Medically Needy (Continued) 42 CFR 435.212 & [ ] 3. The State deems as eligible those individuals who became l 902(e)(2) ofthe otherwise ineligible for Medicaid while enrolled in Act, P .L. 99-272 an HMO qualified under Title XIU of the Public Health (section 9517) P.L. 101-508 Service Act, or a managed care organization (MCO), or a (section4732) primary care case management (PCCM) program, but who have been enrolled in the entity for less than the minimum enrollment period listed below. Coverage under this section is limited to MCO or PCCM services and family planning services described in section 1905(a)(4)(C) of the Act. The State elects not to guarantee eligibility. The State elects to guarantee eligibility. The minimum enrollment period is __ months (not to exceed six). The State measures the minimum enrollment period from: [ ] The date beginning the period of enrollment in the MCO or PCCM; without any intervening disenrollment, regardless of Medicaid eligibility. [ ] The date beginning the period of enrollment in the MCO or PCCM as a Medicaid patient (including periods when payment is made under this section), without any intervening disenrollment. [ ] The date beginning the last period of enrollment in the MCO or PCCM as a Medicaid patient (not including periods when payment is made under this section) without any intervening disenrollment or periods of enrollment as a ,,,. privately paying patient. (A new minimum enrollment period begins each time the individual becomes Medicaid eligible other than under this section). *Agency that determines eligibility for coverage. ---=x- NotApplicable TN# 03~09_ Effective Date 08 I 13 I 0 3 Supersedes TN #~9'"""2,__-1~0,__ _ Approval Date fEB 2 4 iR Revision: HCFA-PM-91-1-4 Attachment2.2-A DECEMBER 1991 (BPD) 0.fflCIA:l Page lOa Stme:.~__ __,_[~P~ue~rt~o~Ri~·c~o~l---~------'------Agency* Citation(s) Groups Covered B. Optional Groups Other Than Medically Needy continued) The Medicaid Agencymay elect to restrict the disenrollment of Medicaid enrollees of MCOs, PIHPs, P AHPs, and PCCMs in l 932(a)(4) of Act accordance with the regulationsat 42 CFR 438.56 . This requirement applies unless a recipient can demonstrate good cause for disenrolling or if he/she moves out of the entity's service area or becomes ineligible. Disenrollment rights are restricted for a period of __ months (not to exceed 1l.months). During the first three months of each enrollment period the recipient may disenroll without cause. The State will provide notification, at least once per year, to recipients enrolled with such organization of their right to and restrictions of terminating such enrollment. No restrictions upon disenrollment rights. 1903(m)(2)(H), In the case of individuals who have become · 1902(a)(52) of ineligible for Medicaid for the brief period described in the Act section 1903(m)(2)(H) and who were enrolled with an P.L. 101-508 MCO, PIHP, PAHP, or PCCM when they became ineligible, the 42 CFR 438.56(g) Medicaid agency may elect to reenroll those individuals in the same entity if that entity still has a contract. The agency elects to reenroll the above individuals .who are ineligible in a month but in the succeeding two months become eligible, into the same entity in which they were enrolled at the time eligibility was lost. ,,~ The agency elects not to reenroll above individuals into the same entity in which they were previously enrolled. * Agency that determines eligibility for coverage. -=x_Not Applicable 1N# 03-03 EffectiveDate 08/13/03 Supersedes 1N #--'9"""2,,,..-...::..1""'0 _ ApprovalDate FEB 2 4 imM Revision: HCFA-PM-91-10 (MB) Attachment 2. 2-A DECEMBER 1991 Page 11 State/Territory: Puerto Rico Agency* Citation{.s) Groups Covered B. Optional Groups Other Than the Medically Needy (Continued) 42 CFR 435.217 4. A group or groups qf individuals who would be eligible for Medicaid under the plan if they were in a NF or an ICF/MR, who but for the provision of home and community-based services under a waiver granted under 42 CFR Part 441, Subpart G would require institutionalization, and who will receive home and community-based services under the waiver. The group or groups covered are listed in the waiver request. This option is effective on the effective date of .the State's section 1915(c) waiver under which this group(s) is covered. In the event an existing 1915(c) waiver is amended to cover this group(s), this option is effective on the effective date of the amendment. Not Applicable *Agency that determines eligibility for coverage. TN No. ft1i.11) Approval Date ceT 14 1992Effective Date JUL J 1992 Superse'?;.e;., _ ..., TN No. ~d- HCFA II;>: 7983E Revision: HCFA-PM-91-4 '(BP,0) Offl&\Al ATTACHMENT 2.2-A . ·AUGUST 1991 Page .12. OMB No.: ()939.:.. . Territory: Puerto Rico Agency* Citation(s) Groups Covered: B. Option.al Grouos Other Than the Medically Needy Continued) '··· .. 1902 (a) . 7. • Individuals. who are in institutions for at ·(10) (A) (11) least 30 consecutive days and who· are (V) of the eligible under a special income level. Act Eligibility begins. on the first day of _the 30'-day period. These individuals .meet the.income standards .specifie~ in to 2·. 6-A. Supplement 1 Attachmentt -, The. State covers all individuals as described· ~~. I The State.covers only the following .9roup or· g~oups of.individuals: . Aged -· Blind Disable'd Individuals under the ag~-af-,, 21· .( 20 \.. 19 18 Caretaker relatives· Preanant woman: TN No• . M-4: . . · .tjAY 1 19QZ JAN 1 - 1992 · supersede!'n:' Approval 'Date Effective Date~------TN No. ~!!..-. I · . HCFA ID: 7984E Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12124120.14 Transmittal No: 92-2 Uttl&IAL Revision: HCFA-PM-91- 4 (BPD) ATTACHMENT 2.2-A. .AUGUST 1991 'Page _i6·'. . : OMB No.: .· Q938- · Territory: Puerto'Rico Ag'enpy* Citation(s) .. Groups Covered B. Opt'ional Groups Other Than the Medicallv Needy iCQntinued\ 42 CFR 436.230. x 11. · Essential spouse of a ·recipient of: .~oAA· ~AB ~!\PTO _! AABD spouse is living with and determJ,ned essential' .to the well being of the recipient of O~, AB, APTD, DOH or AABD, and his (he~).needs·are·taken.into consideration in determining the amount of· financi"al ,ass.istance. · TN No. 94-/J· . · .MAY 1 1B82 Effective Date JAt>I 1 - 1Q92 Supersedes0 0 l Approval Date _;...· ---- TN No. o a .. HCFA ID: 7984E Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 ~evisio~: HCFA-PM-92-1 {MB) . AT~ACHMENT 2.2-A . FEBRUARY 1992 Page 18 ·STATE PLAN UNDER TITLE XIX OF THE SOOIAD SEC'ORITY ACT Terri:toryi . . PUERTO RICO COVERAGE AND CONDITIONS· OF ELIGIBILITY ci.tation(s) ·Gr9ups Covered B. · j]tional Groups other Than the Medic~lly Needy ~ontinued) · · "' 1902(a){l0) 14. Individuals-- (A)Tii) (X) and. 1902(~){1)· & (2) ·a •. Who are 65 years old.or older or are of the Act disabled as.determined under section 161.4 of the 'Act;. b. · · Who~e i~~ome does not exceed the income level ( estB.b;tished at an amou#t .. up to. · , •• 1· 100 percent of the 'Federal income poverty_level) specified in suPjOlement: 1 to ATTACHMENT 2.6-A for a fam ly of th~ same size; and · · · · .c, Whci.se resource·s ·do not exceed the · maximum amount allowed under SSI or Uild~r ·the Sta't;,BI 8 inediC.~lly:,'..ne~dY: ...... ··:··. prc9.?¥am. NOT APPLICABLE Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 } Transmittal No: 92-4 t ..... TN No.. q ;;2- t/" JUL ). - 19&!] ·supersedes q 'l · . Apptoval Date _{J_C_T_8_.;.;:19;..:;92=-- Effective Date TN No • d', - ;;).._ ------. ' 'I=:::~r:~::'.:;. ~·~r-:~.:~:r:,:~~::~·~.··· :·:': . -r- •• : • .- ·'·-·: - ::~.;.··~:.ii::~·: - -~~~~~v---:~---~ ----·- -·-- :·~ - . ~- .. -.- ~··:-"7'""~ .. - - .. ::- - ... OFFJ:C.IAL Revision: HCFA-PM-91-4 (BPD) ATTACHMENT 2.2-A AUGUST 1991 Page 19 OMB No.: 0938- . Territory: Puerto Rico Agency* Citation(s) Groups Covered c. Optional Coverage - Medically Needy 42 CFR 436.301 This plan includes the medically needy. No . .A_ Yes. This plan covers:. 1902(a)(10) 1. Pregnant women who, except fo-,: income (C)(ii)('II) and/or resources, would be eli~ible as of the Act categorically needy under title ·xrx of the Act. · 1902{e) of i. Women who, while pregnant, were eligible the Act for and have applied for Medicaid and receive Medicaid as medically needy under the approved State plan on the day the pregnancy ends. These women continue.to remain eligible, as though they were pregnant, for ali pregnancy-related and postpartum medical a~sistance under the plan for a 60-day period (beginning on the last day of pregnancy) and for any remaining days in the month in which the 60th day falls. 1902(a)(l0} 3. Individuals under age 18 who, but for (C)(ii}{I) income and/or resources, would be eligible of the Act under section 1902(a) (10) (A) (i) of the Act. TN No • 94 -C6 MAY 1 JAN 1 - 1992 Superse~ Approval Date . 1992 Effective Date TN No. -PJew; ' HCFA IO: 7984E Revision: HCFA-PM-92-1 {MB}" ATTACHMENT 2.2-A . FEBRUARY 19~2 OFFICIAL Page 20 ~ ... : . . I ' • • ~ . ' STA~ PLAN UNDE'R. TITLE XIX OF THE SOCIA.4 SECURITY ACT Territory: PUERTO RICO· COVERAGE AND CONDITIONS OF ELIGIBILITY Ci:tation ( s) Groups Covered' 'c, Optional coverage - M~dic~lly Needy '·{Continued) 1902(e) (4) of· the Act. ' 42· CFR "436.308 X 5. ··a, Financially eligible indiv~du8:11;1 :who are ·not described in section C.3. abeve and· who ~re unde~·the age of-- 1902(a)(10) . ·X 2·1. (C) (ii) of -· 20 the Act 19 18 or under erge as.. ~}:io · 8.1;~.,,.fUJ:l:""-time·. . . :· students in a secondal:;'y :~chool or' .in . tha equivalent level ··of voc~tional or technical train~ng. ... : r . . - .. '""'•·: «. Transmittal No: 13-006 Effective Date: 01/01/2014 )· Partial Supersedes: Approval Date: 12/24/2014 ) Transmittal No: 92-4 TN No. la-Y: ·· OCT 9 . 1.9Ni superseqes q Approval 'Date - - '?4. Effective ·oate ~mt. 1- .199!\ TN_ No. _;l .:..J: . . ~ . - -•r--~~~~~-~-- -~···~ .. ~-~·{.~ .. :~·::·:·:. ,:::.: :. ;;i;i;:~~·::::::·~ .. ~· =: : :·:··~:· "'····17---- ··~~~~? ~~:."·;.~~. ·: ··· ~~·· --~~"'"'''.:~~ ·~-~"'"''Z'~ =":··~ r . •• • • t• • • •• :. ~ Revision: HCFA~PM-91-4 ATTACHMENT 2.2-A AUGUST 1991 (BPD) nn\t\M. Page 21 OMB No.: 0938- Territory: Puerto Rico Agency* Citation(s~ Groups Covered· C. Optional Coverage - Medically Needy (Continued) b. Reasonable classifications of financially eligible individuals under the ages of 21, 20, i9, or 18 as specified belowr (1) Individuals for whom public agencies are assuming full or partial financial respons~bil~ty and who are: (a) rn· foster homes (and are under th~ age o.f ) . (b ) In private ·institutions (and are under the age of ). (c) In addition to the group under b.(l)(a) and (b), individuals placed ·in foster homes Qr private ,-,·_,,;_,., ». institutions by private, nonprofit agencies (and are under the age of _). Effective_ Date JAN l - 1992 HCFA ID: 7984E ~ f OFftG1AL. Revision: HCFA-PM-91- 4 (BPD) ATTACHMENT 2.2-A AUGUST l99l Page 22 · OMB No.: 0938- Territory: ~-P_1~1e~r~t-o~B~i~c~o~~~~~~~~- Agency* Citation(s) Groups Covered c. Optional Coverage - Medically Needy (Continued) (2) Individuals in adoptions subsidized in full or part by a public agency (who are under the age of __ ._). (3) Individuals in NFs (who are under the age of ). NF services are provided under this plan. __ { 4} • In addition to the group under ( b) { 3.) , individuals in ICFs/MR (who are under the age of ). __ (5) Individuals receiving active treatment a2 inpatients in psychiatric facilities or progra~s {who are under the age of ___ ). Inpatient psychiatric services for individuals und~r age 21 are providec under this plan. __ (6) Other denied groups (and ages), as specified in Supplement 1 of ATTACHMENT 2 .2-A. . 42 CFR 436.310 __x_ 6. Caretaker Relatives. DOH 42 CFR 436.320 _x_ 7. Aged Indlviduals. 42 CFR 436.321 --X- a. Blind Individuals. 42 CFR 436.322 x 9 . Disabled Individuals. TN No .. .._....,..__.~~ . MAY 1 · JAN l - 1992 Superse oate .1- Effective Date TN No. HCFA ID: 7984E ( \ OFFICIAL ~evision: HCFA-PM-93- 5 (MB) ATTACHMENT 2.2-A MAY· 1993 . Page 23 Territory: Puerto Rico . Agency* Citation(s) Groups .Covered D. Optional Coverage - Qualified Medicare Beneficiaries 1902.(a)'(lO) (E) (i) Qualified Medicare Beneficiaries-- and 1905(p)(4) of the Act 1. Who are entitled to hospital insurance benefits under Medicare Part A, (but not pursuant to an enrollment under section 1818A of the Act); 2. Whose income does not exceed the percent of the Federal poverty level specified in Supplement 1 to ATTACHMENT 2·, 6-A ; and · 3. Whose resources do not exceed twice the maximum standard under ssr . . 190S{p) (3) (Medical assistance for this g~oup is limited to Medicare of.the Act cost-sharing as defined in section 1905(p)(3) of the Act). Not Appl i cab] e ~ .{ .• .. ·- .·· TN No. 93-S JAN. 11 1994 Supersedes Approval Date Effective Date JUL 1 - 1993 TN No. 9 ~-¢._, OFFICIAL Revision: HCFA-PM-91- 8 (MB) ATTACHMENT 2.2-A October 1991 Page 23a · OMB NO.:· State/Territory: PUERTO RICO ·Citation Groups Covered B. Optional.Groups Other Than the Medically Needy {Continued) 1906. of the 18. Individuals required to enroll in Act cost-effective employer-based group health plans remain eligible for· a minimum enrollment period of 12 .months. 1902(a)(lO)(F) 19. ·Individuals entitled to eiect COBRA and 1902(u)(l). continuation coverage arid whose of the Act income as determined under Section 1612 of the Act for purposes of the SSI program, is no more than 100 percent of the Federal poverty level, whose resources are no more than twice the SSI c· resource limit for an individual, and for whom the State determines that the cost of COBRA premiums Ls likely to be less than the Medicaid extendi tures for an equivalent set of service~. See Supplement 11 to Attachment 2.6-A. Not Applicable TN No. ~~-8 14 Superce~_} · .. Approval Date OCT 1992 Effective Date JJJL 1 1992 TN No. PJf:Wi . HCFA ID: 7982E ( . ' Revision: HCFA-PM-(MB) Attachment 2.2-A February 1998 Page23d STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Territory: ...,P...;::;u:...:::e..... rt=o::...... :.,;R:..:.;ic::;.;o=------ COVERAGE AND CONDITIONS OF ELIGIBILITY Citation (sl Groups Covered . USED TO ESTABLISH COUNTABLE INCOME AND RESOURCES)." 1902 (e} (12) _ 20. A chlld under age '·, (not to exceed ·of the Act age 19) who has been determined eligible Is deemed to be eligible for a total of __ months (not to exceed 12 months).regardless of changes In Not applicable clrcumsstances other than attainment of the maximum age stated above. Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 98-001 . -.'JON 2 A ~Q··. . . TN #98-001 Approval Date '- :it f v 98 . Supersedes · JAi 1 IHI · Effective Date _ TN#Nnw 'I . 'el ! i I i i ~ I '! ~·_: ······--·.---··-·----.-·-···---·--r--··-··~-- Revision: HCFA-PM-93- 5 (MB) ATTACHMENT 2. 2-PFFICIAL .. - ---· ···-~-· }iAY-199-3·-- ·· ·· P ag~---~ 4_, --~~-.,·--~,____.,.:,~...,...~-~~ ..., _. ·--:--··--··--.- . Territory: Puerto Rico Agency* Citation(s) Groups Covered E. Optional Coverage - Qualified Disabled and Working Individuals 1905(p)(3)(A)(i) (Medical assistance for this group is limited to cost-sharing as defined in section 1905(p)(3)(A) (i) of the Act.) ( F. Optional Coverage - Specified Low-Income Medicare \ ,. Beneficiaries 1902(a)(10)(E)(iii) Specified low-income Medicare beneficiaries-- and l905(p)(4) of the Act l. Who are entitled to hospital insurance benefits· under Medicare Part A (but not pursuant. to an enrollment under section 181BA of· the Act); · 2. Whose income for· calendar years begLnning 1993 exceeds the percent of the Federal poverty level in D. 2. , but is less than the percentage of the Federal poverty level specified in Supplement 1 to ATTACHMENT 2.6-A; · 3. · Whose resources do not exceed twice the maximum l standard under SSI. i'l 1905(p)(3)(a)(ii} (Medical assistance for this group is limited to ! of the Act cost-sharing as defined in sectio~ 1905(p)(3)(A)(ii) ~I of the Act.} I I Not Applicable I ( "' \., J TN No. q 3-S JUL 1 - 1993 Supersedes Approval Date JAN 11 1994 · Effective Date ™ No. qa -.a Revision: HCFA-PM-91-8. (BPD) DFFICIAbTTACHMENT · Page·-26·cc··· ... ., ··· -~------~---.··· OMB NO.: 0938- State: P!IERTO RICO Citation(s) Groups Covered c. Optional.Coverage of Medically Needy (Continued) 1906 of the 12. Individuals required to enroll in Act cost effective employer-based group heal th plans remain eligi~le for a minimum enrollment period of 12 mcnt.hs i TN 9 {)_i Approval Date OCT 1 4 1992 Supers~des TN .New Effective Date JUL 1 1992 "r;<.. Revision: HCFA-PH-85-3 (BERC) SUPPLBKIWT 1 TO ATTACHMDTT 2 .·2-A MAY 1985 Pagel OHB BO.: 0938-0193 STATE PLAIT UIJDER TITL! XIX OF THB SOCIAL SBCURITY ACT Puerto Rico State: RKASOIJABLE CLASSIFICATIOllS OF IIJDIVIDUALS UllDBR THE AGE OF 21, 20, 19, Alfl> 18 ..... :ii Bo. $5'-?. 1 19~6 1 1985 supersedes Approval Date JUN. · 9 Bffectlve D~te jUL. TIJ llo. f62. -? HCFA ID: 0022P/0002P DlrmtAL( Revision: HCFA-PM-87-4 (BERC) SUPPLEMENT 2 TO ATTACHMENT 2.2-A MARCH 1987 Page 1 ( OMB No.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Terdtory: Puerto Rico ,. I A. DEFINITION OF BLINDNESS IN TERMS OF OPHTHALMIC MEASUREMENT \ An individual is considered blind iI he has central visual acuity of 20/200 or less in the better eye with CDrrecting glasses or a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance of no greater than 20°. • ~ • I • I -;•,:r . .',;·. --'*!'~<.-~"'<'<'· _ _,, ,., '. ··.,;.!\..!.· ~ . . " . i.*li~:;:i~~/l::;'•, ~~ ... A "r"' .,.,i~li;.;fa~;' :t;::·~;_'.: '. .· ~ ", -~- ,,.,, ·. . ~ ··-~'- *Agency that determines eligibility for covera~ L TN' No. 88- I ·.811'•1·0 It( super:-sedes Approval Date · . \ \ ;i Effective Date TN No. Al~ 2002P/0021P 1 Revision: HCFA-PM-87-4 (BERC) ' omc1•• I ~PPLEMENT 2 TO ATTACHMIWT 2.2-A MARCH 1987 Page 2 ( OMB No.: 0938-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Terdtory: Puerto Rico B. DEFINITION OF PERMANENT AND TOTAL DISABILITY 11 Permanently and totally disabled". means that the individual has some permanent physical or mental impediment disease or loss, or combination thereof, that substantially precludes him from engaging in useful occupations within his competence, such as holding a job . .rj,,:~ N~-"< ·,·_-;' .,~jf:'r?..~~Sl,:, __ , ~~.f}~~~·;:;~§.~j;v·ii;i· "}.,·~•4,~.~ t • ~~.~tll~k~~--~ -' ,_.,: ,'~" *j ~ .. . ~·f.f;1j~if~~~~Vr'\~--):h•I ,'.t!:,, -~; · ' . - '. ..;,. I !! I I' ~I I .. ·. . .. ( -; -, *Agency that determines eligibility for coverage. TN No. ~&---I Supet'sedes Appl'oval TN No . A/ UV-- OfflC·U\l Revision: HCFA-PM-91-4 (BPD) SUPPLEMENT 3 TO ATTACHMENT 2.2-A AUGUST 1991 Page 1 OMB NO.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Puerto Rico Method for Determining Cost Effectiveness of Caring for Certain Disabled Children At Home Not Applicable TN No. 9<;2-QJ, 1992 Supersed~ Approval Date MAY 1 Effective Date !A,N 1- 1992 TN No. ew HCFA ID: 7983E ------~------:------·~ ..... Medicaid Eligibility State Name:jL_Pu_e_rt_o_Ri_._co __. TransmittalNumber: PR -13 - 0006 Indicate which type of poverty level the territory uses: C The Federal Poverty Level (FPL) (9-. The Local Poverty Level (LPL) Enter the amount of the Local Poverty Level. Household Size Amount i $459.00 2 $542.00 3 $626.00 4 $709.00 5 $792.00 6 ,., $876.00 7 $959.00 8 $1,043 ..00 9 $1,126.00 10 $1,210.00 11 $1,293.00 12 $1,377.00 13 $1,460.00 $1,544.00 $1,627.00 Jm $1,711.00 ·= $1,794.00 $1,877.00 JM~c~~-B'~gther the amounts entered abov~prpr%1S~~t~?i~}2~;2014 Effective Date: 01/01/2014 PUERTO RlCO S14T Medicaid Eligibility Wherever FPL is referenced in the other sections of the state plan, it means the Local Poverty Level. Enter the AFDC Standards below. A 11 states must enter: MAGINequivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. The standard is as follows: l- Statewide standard (' Standard varies by region r. Standard varies by living arrangement (' Standard varies in some other way Household size Standard ($) Additional incremental amount @.Yes CNo 1 37 Increment amount $136 2 70 3 103 4 135 5 168 6 201 J! 234 li 267 The doJ!ar amounts increase automatically each year c: Yes TN: 13-006 A roval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO S14T Medicaid Eligibility The standard is as follows: r.., Statewide standard ('. Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way Additional incremental amount Household size Standard ($) ~Yes C' No 32 Increment amount s ._13_2__ --l 2 64 3 96 4 128 5 160 192 224 256 The dollar amounts increase automatically each year C' Yes ~'No The standard is as follows: 6?· Statewide standard C' Standard varies by region ( \ C Standard varies by living arrangement (' Standard varies in some other way PUERTO RICO S14T Medicaid Eligibility Additional incremental amount ('Yes ('No Increment amount $ I The dollar amounts increase automatically each year ('.Yes ('.No I The standard is as follows: ('. Statewide standard C Standard varies by region C Standard varies by living arrangement C Standard varies in some other way The dollar amounts increase automatically each year c Yes ("'.No The standard is as follows: (' Statewide standard ('. Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year ('Yes C No PUERTO RICO S14T I Medicaid Eligibility The standard is as follows: (' Statewide standard C Standard varies by region C Standard varies by living arrangement C Standard varies in some other way The dollar amounts increase automatically each year (' Yes ('No The standard is as follows: , (' Statewide standard (' Standard varies by region (' Standard varies by living arrangement (' Standard varies in some other way The dollar amounts increase automatically each year ('.Yes ('No . i· ' The standard is as follows: (' Statewide standard f (: Standard varies by region C Standard varies by living arrangement (': Standard varies in some other way The dollar amounts increase automatically each year (' Yes ('No V.20140415 TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO ,514T Medicaid Eligibility State Name:jPuerto Rico Transmittal Number: PR - 13 - 0006 42CFR435.118 1902(a)(IO)(A)(i)(III), (IV), (VI) and (VII) l 902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) 1920A . . ~ Infants and Children under Age 19 - Territories - Infants and children under age 19 with household income at or belgw standards • established by the state based on age group. 0 The state attests that it operates this eligibility group in accordance with the following provisions: l!J Children qualifying under this eligibility group must meet the following criteria: [!] Are under age 19 [!] Have household income at or below the standard established by the state. r.i MAGI-based income methodologies are used in calculating household income. Please refer as necessary to Sl 0 MAGI~ . i!J Based Income Methodologies, completed .by the state. · ~ Income standard used for infants under age one [!] Minimum income standard The minimum income standard used for infants under age one is the state's AFDC payment standard in effect as of May l, 1988, converted to MAGI-equivalentamoun ts by household size. The standard is described in Sl4T Income Standards-Territories. [ZJ The state certifies that it has an approved MAGI conversion plan. 00 Income standard chosen The state's income standard used for infants under age one (which cannot be less than the highest effective income level for coverage of infants under age one in the state plan as ofMarch 23, 2010) is: { Ifhigherthan the highest effective income level for this age group under the state plan as of March 23, 2010, the minimum income standard. The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income { families), l 902(~~(10)(AXi~(III) (qualified children), 1~02(a)(lO)(A)(i)(IV) (pove~ level-~ela~ed ~fan.ts), . 1902(a)(lO)(A}(u)(IX) (optional poverty level-related infants) and l 902(a)(lO)(A){u)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income (i' families), 1902(a)(I O)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (poverty level-related infants), 1902(a)(lO)(A)(ii)(lX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized TN: 13_0olJildren), in effect under the Me,i,.\s~lttm!W:a~2f!lf~r31, 2013, ~m~~t9at Mim¥@!W!'Oltt1nt. Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23; 2010, the (" state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 20 I 0, converted to a MAGI-equivalent. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, the (' state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent. (' Another income standard higher than the minimum standard allowed, provided it is higher than the highest effective income level for this age group under the state plan as of'March 23, 2010. The amount of the income standard for infants under age one is (ifnot the minimum): (' AFDC Payment Standard in Effect As of July 16, 1996. The standard is described in Sl4T Income Standards-Territories. (' MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996. The standard is described in SI4T Income Standards- Territories. C AFDC Need Standard in Effect As of July 16, 1996. The standard is described in Sl4T Income Standards• Territories. AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in C the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14'r Income Standards-Territories. · MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the r percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in Sl4T Income Standards-Territories. (' TANF payment standard. The standard is described in Sl4T Income Standards-Territories. MAGI-~uivalent TANF payment standard. The standard is described in S14T Income Standards• (': Territories. c-.' Another income standard not already specified in Sl4T Income Standards-Territories. (i' A percentage of the poverty level: C A dollar amount by family size !!] Income standard for children age one through age five, inclusive !!] Minimum income standard The minimum income standard used for children age one through five is the state's AFDC payment standard in effect as of May I, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14T Income Standards-Territories. ~ Income standard chosen The state's income standard used for children age one through five (which cannot be less than the highest effective income level for coverage of children age one through five in the state plan as of March 23, 201 O) is: TN: 13-006 Approva PUERTO RICO I j Medicaid Eligibility I I *j (' If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, the !! minimum income standard. i The state's highest effective income level for coverage of children age one through five under sections I931 (low- C income families), 1902(a)(10)(A)(i)(II1) (qualified children), 1902(a)(10)(A)(i)(VI) (poverty level-related children age one through five), and I 902(a)(lO)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent. If higher than the highest effective income level for this age group under the state plan as of March 23, 20 I 0, the state's highest effective income level for coverage of children age one through five under sections 1931 (low- (-' income families), 1902(a)(IO)(A)(i)(lll) (qualified children), 1902(a)(IO)(A)(i)(VI) (Poverty level-related children age one through five), and l 902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent. If'higher than the highest effective income level for this age group under the state plan as ofMarch 23, 2010, the (: state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as ofMarch 23, 2010, converted to a MAGI-equivalent. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, the (' state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent. (> Another income standard higher than the minimum standard allowed, provided it is higher than the highest effective income level for this age group under the state plan as of March 23, 2010. The amount of the income standard for children age one through five is (if not the minimum): (' AFDC Payment Standard in Effect As of July 16, 1996. The standard is described in S14T Income Standards-Territories. (' MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996. The standard is described in Sl4T Income Standards-Territories. C AFDC Need Standard in Effect As of July 16, 1996. The standard is described in S 14T Income Standards• Territories. AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in C the Consumer Price Index for urban consumers (CPl·U) since such date. The standard is described in SI4T Income Standards-Territories. MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the (' percentage increase in the Consumer Price Index for urban consumers (CPl-U) since such date. The standard is described in S 14T Income Standards-Territories. (' TANF payment standard. The standard is described in S14T Income Standards-Territories. (' MAGI-equivalent TANF payment standard. The standard is described in Sl4T Income Standards• Territories. l-" Another income standard not already specified in SI 4T Income Standards-Territories. ' (i: A percentage of the poverty level: ~ % (' A dollar amount by family size Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO S30T Medicaid Eligibility lil Income standard for children age six through age eighteen, inclusive [!] Minimum income standard . The minimum income standard used for children age six through eighteen is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in Sl4T Income Standards-Territories. [!] Income standard chosen The state's income standard used for children age six through eighteen (which cannot be less than the highest effective income level for coverage of children age six through eighteen in the state plan as of March 23, 2010) is: (' If higher than the highest effective income level for this age group under the state plan as ofMarch 23, 2010, the minimum income standard. The state's highest effective income level for coverage of children age six. through eighteen under sections 1931 (low-income families), l902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (poverty level-related C children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low- &. income families), 1902(a)(IO)(A)(i)(III) (qualified children), 1902(a)(lO)(A)(i)(VII) (poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI·equivalent. If higher than the highest effective income level for this age group under the state plan as of March 23, 20 IO, the \' state's effective income level for any population of children age six through eighteen under a- Medicaid 1115 demonstration as ofMarch 23, 2010, converted to a MAGI-equivalent. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, the (' state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent. (" Another income standard higher than the minimum standard allowed, provided it is higher than the highest effective income level for this age group under the state plan as of March 23, 20 I 0. The amount of the income standard for children age six through eighteen is (ifnot the minimum): (' AFDC Payment Standard in Effect As of July 16, 1996. The standard is described in Sl4T Income Standards-Territories, (' MAGI-equivaient AFDC Payment Standard in Effect As of July 16, 1996. The standard is described in S14T Income Standards-Territories. (' AFDC Need Standard in Effect As of July 16, 1996. The standard is described in S14T Income Standards• Territories. AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in (' the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in Sl4T Income Standards-Territories. MAGI-equivalent AFDC Payment Standard in Effect As ofJuiy 16, 1996, increased by no more than the (' percentage increase in the Consumer Price Index for urban consumers (CPI~U) since such date. The standard is described in S 14 T Income Standards-Territories. (' TANF payment standard. The standard is descdb;;,d iJl.Sl4T Income Standards-Te.rritori~l/Ol/201 TN: 13-006 ApprovalDate: 1l.;L4/L0 4 Effectiveuate: u 4 l'Ut:!i.lU KILU Medicaid Eligibility l MAGI-equivalent TANF payment standard. The standard is described in S14Tlncome Standards• . Territories. lo'· Another income standard not already specified in Sl4T Income Standards-Territories. (O'. A percentage of the poverty level: (' A dol1ar amount by family size ~ There is no resource test for this eligibility group. lj] Presumptive Eligibility The state covers children when determined presumptively eligible by a qualified entity. V.20140415 TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO S30T Medicaid Eligibility OMB Control Number: 0938-1148 State Name:IPtierto Rico Transmittal Number: PR - 13 - 0006 Expiration date: 10/31/2014 42 CFR435.1 l0 1902(a )(lO)(A )(i)(I) 193l(b) and (d) liil Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or ~ . below a standard established by the state. . f [Z] The state attests that it operates this eligibility group in accordance with the following provisions: Ii] Individuals qualifying under this eligibility group must meet the following criteria: ~ Are parents or other caretaker relatives (defined at 42 CFR 43 5 .4), including pregnant women, of dependent children • (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, D provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. D Options relating to the definition of caretaker relative (select any that apply): [gJ Options relating to the defrnition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or {e· care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. (' The child must be deprived of parental support or care, but a less restrictive standard is used to measure t· .. unemployment of the parent (select the one that applies): · [!l Have household income at or below the standard established by the state. [jJ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to 810 MAGI• Based Income Methodologies, completed by the state. [!l Income standard used for this group [jJ Minimum income standard The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, . converted to MAGI-equivalent amounts by household size. The standard is described in 814 AFDC Income Standards. [Z] The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. TN: ~-1l0Ji.imwn income standard Approval Date: 12/24/2014 Effective Date: 01/01/2014 Medicaid Eligibility The state certifies that it has submitted and received approval for its converted income standard(s) for parents and 1ZJ other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. The state's maximum income standard for this eligibility group is: ' I C The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, t I ·· converted to a MAGI-equivalent percent of FPL or amounts by household size. r. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalentperce nt of FPL or amounts by household size. I The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 (: demonstration as of March 23, 2010, converted to a MAGI-e.quivalent percent of FPL or amounts by household I size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 ~ (' demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by 'Ii household size, t ! Enter the amount of the maximum income standard: I I ~: A percentage of the federal poverty level: §=:::] % I C The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI~equivalent standard. The standard is described in 814 AFDC Income Standards. Iu The state's AFDC payment standard in effect as of July 16, l 996, increased by no more than the percentage i JI (' increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI• g k equivalent standard. The standard is described in S14 AFDC Income Standards. ~ f g ! (' The state's T ANF payment standard, converted to a Ma.Gl-equivalent standard. The standard is described in S 14 AFDC Income Standards. (': Other dollar amount 00 Income standard chosen; Indicate the state's income standard used for this eligibility group: (' The minimum income standard (9 The maximum income standard The state's AFDC payments tandard in effect as of July 16, 1996, increased by no more than the percentage (' increase in the Consumer Price Index for urban consumers (CPI~U) since such date. The standard jg described in Sl4 AFDC Income Standards. ( (' Another income standard in-between the minimum and maximum standards allowed I!] There is no resource test for this eligibility group. iil: ~~tive Eligibility Approval Date: 12/24/2014 Effective Date: 01/01/2014 '--~---..PU~EnR~T~O~R~lc~a~~~~~~~~'--~~----=s2~s-::--'--'--~~~~~~~~~---...:.....:....::::'.~f=-:_: !~ ~--1 ~r Medicaid Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR435.116) and/or Infants and Children under Age 19 (42 CFR 43 5 .118) eligibility groups when determined presumptively eligible. ('Yes C- No f PRA Disclosme Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20140415 TN: 13-006 · Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO 525 Medicaid Eligibility State Name:jPuerto Rico Transmittal Number: PR - 13 - 0006 f 42 CFR435.116 l902(a)(10)(A)(i)(IJI) and (IV) 1902(a)(IO)(A)(ii)(l), (IV) and (IX) 193 l(b) and (d) 1920 00 Pregnant Women -Territories Women who are pregnant or post-partum, with household income at or below a standard established by the state. IZJ The state attests that it operates this eligibility group in accordance with the following provisions: [!l Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. Pregnantwomen in the last trimester of their pregnancy without dependent children are eligible for full benefits Bes under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan S25 - Parents and Other Caretaker Relatives. l!l MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI-Based Income Methodologies, completed by the state. (!l Income standard used for this group 00 Minimum income standard The minimum income standard used for this group is the state's AFDC payment standard in effect as of May l, 1988, converted to MAGI-equivalent amounts by household size, The standard is described in Sl4T Income Standards• Territories. [{] The state certifies that it has an approved MAGI conversion plan. ~ Income standard chosen Indicate the state's income standard used for this eligibility group: C The minimum income standard The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(lll) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (poverty level-related (' pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10)(A)(ii)(J) (pregnant women who meet AFDC fmancial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 20 l 0, converted to a MAGI~equivalent. / 1;. TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO S28T Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(IO)(A)(i)(I1I) (qualified pregnant women), 1902(a)(IO)(A)(i)(IV) (poverty level-related t pregnant women), 1902(a)(l O)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(l O)(A)(ii)(I) . (e' (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(IO)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGJ.. equivalent. (' The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent. C The state's effective income level for any population of pregnant women under a Medicaid 11I5 demonstration as of December 31, 2013, converted to a MAGI-equivalent. C Another income standard higher than the minimum standard allowed. The amount of the income standard for this eligibility group is (ifnot the minimum): (- AFDC Payment Standard in Effect As of July 16, 1996. The standard is described in S 14T Income Standards-Territories. · (' MAGI-equivalent AFDC Payment Standard in Effect As ofJuly 16, 1996. The standard is described in Sl4T Income Standards-Territories. r. AFDC Need Standard in Effect As of July 16, 1996. The standard is described in Sl4Tincome Standards- t.·.· . Territories. AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in C the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14T Income Standards- Territories. MAGI-equivalent AFDC Payment Standard in Effect As of July I 6, 1996, increased by no more than the (' percentage increase "in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S 14T Income Standards-Territories. (' TANF payment standard. The standard is described in S14T Income Standards-Territories. C MAG I-equivalent T ANF payment standard. The standard is described in S 14 T Income Standards• Territories. l-- Another income standard not already specified in Sl4T Income Standards-Territories. @ A percentage of the poverty level; ~% r A dollar amount by family size ~ There is no resource test for this eligibility group. ~Benefits for individuals in this eligibility group consist of the following: f ~ ·All pregnant women eligible under this group receive full Medicaid coverage under this state plan. (' Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. PUERTO RICO S28T · Medicaid Eligibility .------.·-t·. li] Presumptive Eligibility The state covers ambulatory prenatal care for individuals· under this group when determined presumptively eligible r:=-i by a qualified entity. . ~ · V.20140415 I I TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO S28T .. ------1~-!ii. Medicaid Eligibility State Name: !Puerto Rico OMB Control Number: 0938-1148 Transmittal Number: PR - 13 - 0006 Expiration date: 10/31/2014 42 CFR435.150 1902(a )(1 O)(A)(i)(IX) !!] Former Foster Care Children - Individuals under the age of 26, not otherwise mandarorily eligible, who were on Medicaid and • in foster care when they turned age 18 or aged out of foster care. · 0 The state attests that it operates this eligibility group under the following provisions: liJ Individuals qualifying under this eligibility group must meet the following criteria: 00 Are under age 26. r-i Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under ~ this group takes precedence over eligibility under the Adult Group. Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state 00 plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster ~are program. The state elects to cover children who were in foster care and on Medicaid in £!ey. state at the time they turned 18 or aged out of the foster care system. l'Yes (.'No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. l'Yes le'0No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance t Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20140415 ( ~· TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO 533 i I Medicaid Eligibility. OMB Control Number 0938- 1148 OMB Expiration date: 10/3112014 1902(a)(lO)(A)(i)(VlJI) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. le' Yes c No ~ Adult Group - Non-pregnant individuals age 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL. [Z] The state attests that it operates this eligibility group in accordance with the following provisions: ~ Individuals qualifying under this eligibility group must meet the following criteria: ~ Have attained age 19 but not age 65. ~ Are not pregnant, ~ Are not entitled to or enrolled for Part A or B Medicare benefits. ~ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan in accordance • with 42 CFR 435, subpart B. Note: In 209(b) states, individuals receiving SSI or deemed to be receiving SSI who do not qualify for mandatory i Medicaid eligibility due to more restrictive requirements may qualify for this eligibility group if otherwise eligible. i ~ Have household income at or below 133% PPL. i ~ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S 10 MAGI-Based ' • Income Methodologies, completed by the state, I 00 There is no resource test for this eligibility group. Parents or other caretaker relatives living with a child under the age specified below are not covered unless the child is I 00 receiving benefits under Medicaid, CHIP or through the Exchange, or otherwise enrolled in minimum essential coverage, as 'I defined in 42 CFR 435.4. ('Under age 19, or I ~ ~ (i; A higher age of children, if any, covered under 42 CFR 43 5 .222 on March 23, 2010: ('Under age 20 I (i; Under age 21 ! II 00 Presumptive Eligibility The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures I it also covers individuals under the Pregnant Women (42 CFR 435.l 16) and/or Infants and Children under Age 19 (42 CFR ~ 435.118) eligibility groups when determined presumptively eligible. ! Ii c Yes (i; No I TN: 14-002-MMl Approval Date: 05/30/2014 Effective Date: 01/01/2014 I Puerto Rico 532 Pm,.P. 1 nf? ~ ~( '·-~s((~~-- ~ Medicaid Eligibility PRA Disclosure Statement According to the Paperwork Reduction Act of I 995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. I' I1!· I ~I I I I TN: 14-002-MMl Approval Date: 05/30/2014 Effective Date: 01/01/2014 I Puerto Rico S32 Page 2 of2 I :(_··-······· Medicaid Eligibility '· State Name: jPuerto Rfoo OMB Control Number: 0938-1148 ! Transmittal Number: PR - 13 - 0006 Expiration date: 10/31/2014 . 1902(a)(l O)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 l905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. (i' Yes ('No [ZI The state attests that it operates this eligibility group in accordance with the following provisions: Ii] Individuals qualifying under this eligibility group must not be eligible for Medicaid under any mandatory eligibility group. r-i MAGI-based income methodologies are used in calculating household income. Please refer as necessary to SlO MAGI- ~ Based Income Methodologies, completed by the state. . The state covered this eligibility group in the state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as .~, of March 23, 2010 or December 31, 2013. Ce'· Yes r No The state also covered this eligibility group in the state plan as of March 23, 20 I 0. (i'. Yes (' No ~Until October 1, 2019, states must include at least those individuals covered as of March 23, 2010, but may cover additional individuals. Effective October l, 2019, states may reduce or eliminate coverage for this group. (!] Individuals are covered under this eligibility group, as follows: (e', All children under age 18 or 19 are covered: (i' Under age 19 (' Under age 18 C The reasonable classification of children covered is: I!] Income standard used for this classification Iii Minimum income standard The income standard for this classification of children must exceed the lowest income standard chosen for children in the age group selected above, under the mandatory Infants and Children under Age 19 eligibility group. I [ ~ Maximum income standard \j TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO 554 Medicaid Eligibility The statecertifies that it has submitted and received approval for its converted income standard(s) for this IZJ classification of children to MAGI-equivalent standards and the determination of the maximum income standard to be used for this classification of children under this eligibility group. The state's maximum income standard for this classification of children (which must exceed the minimum for the classification) is: (' The state's effective income level for this classification of children under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for this classification of children under a Medicaid l 115 demonstration as ofMarch 23, 2010, converted to a MAGI-equivalent percent of FPL. (' The state's effective income level for this classification of children under a Medicaid 1 l 15 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. (' 200%FPL. (' A percentage of the FPL which may exceed the Medicaid Applicable Income Level, defined in section 2l 10(b)(4) of the Act, but by no more than 50 percentage points. r.11 The state's maximum income standard for this classification of children (which must exceed the ~ minimum for the classification) is: ~ Income standard chosen, which must exceed the minimum income standard Individuals qualify under the following income standard: @:- The maximum income standard. (' The state's effective income level for this eligibility group under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 20 I 0, the state's effective (' income level for. this eligibility group under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective ('income level for this eligibility group under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the effective income level used under the state plan as of March 23, 2010, the state's effective (' income level for this eligibility group under a Medicaid 1115 demonstration as of December 31, 2013, ( converted to a MA GI-equivalent percent of FPL. ('If higher than the effective income level used under the state plan as of March 23, 2010, 200% FPL. TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO 554 Medicaid· Eligibility If higher than the effective income level used under the state plan as of March 23, 2010, a percentage of the ~ 0 FPL which may exceed the Medicaid Applicable Income Level, defined in section 2110(b)(4) of the Act, 'Jl but by no more than 50 percentage points. Another income standard in-between the minimum and maximum standards allowed, provided it is higher , (' than the effective income level for this eligibility group in the state plan as of March 23, 2010. The income standard used for this eligibility group is: l.... 2 _6_6_ __, %FPL 00 There is no resource test for this eligibility group. 00 Presumptive Eligibility Presumptive eligibility for this group depends upon the selection of presumptive eligibility for the Infants and Children 00 under Age 19 eligibility group. If presumptive eligibility is done for that group, it is done for this group under the same provisions. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995,.no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete { this information collection is estimated to average 40 hours·per response, including the time to review instructions, search existing data l•. 8•· ' resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimatefs) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. V.20140415. ·. j TN: 13-006 Approval Date: 12/24/2014 Effective Date: 01/01/2014 PUERTO RICO $54 ~· ···-·-·-··-··· .. -- ~---1!~y!_~i~n: HCF~-PM-91- 4 (BPD) ATTACHMENT 2.6-A - ·--· ..-· .Aucrusi-'19 9'1-·-~·-,.-...--~;___:..__ __ ~.,....,..~~~lr:-t--,~'*"'~__,.--_:.. . . &Mi~ NO. i 0§~9= STATE PLAN ·UNDER TITLE XIX OF THE SOCIAL S.ECURITY ACT Territory: Puerto ·Rico ELIGIBILITY CONDITIONS AND REQUIREME~S C'itation Condition o~ Requirement 'A, Each individual covered under the'plan meets the foll~wing ~ond~tions: 42 .CFR Part 436, 1. Is financially eliqibl'e to receive se~\r:icas. subpart G X _:; : 42 ;CFR Part 436, 2. Meets the applicable non-financiol. elJ.gibiHty · • Subpart F conditions. a. (1) Except ·as spac!Ued.under 'itenis A.2.a.(.ii). ·and (iii). bel. ow. for cateqt,;ri9ally neec!_v' · · incilviduals ~· 1902(1), of the (ii) ·For preqnant women ana . 1rihnta :or ·chll.~ren· Act with incomes up ·tQ. a · p&:ir~ent·age of the Federal poverty l,evel · IJ'.'~:red as ''i>!P.ti~nal groups under. sections 19.Q'2(a)( 10) C:Ar{i)(IV), Not Appli.cabie ·.1902(a){lO')(A)(.i·)(VI), and ' .. 1902(a)( lO)(A} (ii)( IX). ·of· the Act, meets the non-financial criteria ot· ·sect'ion 1992(1) of the:Act. · 1902(m) of the (iii) For aqed and.disabled .individuals with Act incomes up.to the .Federal poverty level covered under section 1902(a) (10) (A) (ii) {X) of the· Act, m.ee~s the Not Applicabl'e non-financial criteria of section 1902(m) oi the Act. · · Ef feet! ve Date ,JAN t .. 1992 HCFA ID: 7984E " Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 OFFICIAL , ;~~Y~is:ipn_~--, ,~CFA-PM-93-5 (MB) ATTACHMENT 2.6-A . t-1A\( f99·3------· - --.-.-Page 2-- -- - .. -· ------ STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Territory: PUER1D meo ELIGIBILITY CONDITIONS AND REQUIREMENTS - Cit-ation condition or Requirement b. For the medically needy, meets the non-financial eligibility conditions of 42 CFR Part 436. 1905(p) of the c. For qualified Medicare beneficiaries, meets the -_Act non-financial criteria of section 190S(p) of the Act. 1905(s} of- the d. For qualified disabled and working individuals, -Act meets the non-financial criteria of section l905(s). l902{A)(lO)(E}(iii) e. For specified low-income Medicare beneficiaries, of the Act meets the non-financial criteria of section 1905(p) of the Act. - Not Applicable ,,,- TN No. 93-S Supersedes Approval Date JAN 111994 Effective ·oate -JUL l - 1993 TN No. qd_-;\ ------Revision: HCFA-PM-91- 4 (BPD) AUGUST 1991 Territory: Puerto R j co Citation Condition or Requirement 42.CFR 436.402 3. Is residing in the United States and -- a; Is a citizen; Sec. 245A of the b. Is an alien lawfully admitted for permanent Immigration and · residence,. or otherwise permanently residing Nationality Act in the United States und~r color or law, as defined in 42 CFR 435.408; 1902(a} and 1903(v) c. Is an alien granted .lawful temporary resident of the Act, P.L. status under sections 245A and -210A of the 99-509 (Section 9406) Immigration and Nationality Act if the Se~. 245A(h)(3)(B) of individual is aged, blind, or disabled as the Immigration and defined in ~ection 1614(a)(l) of the Act, ;Nationality Act under 18 years of age, or a Cuban/Haitian entrant as defined in section, 50l(e)(l) and {2)(A) of Public Law 96-422; d. Is an alien granted lawful temporary resident status under section 210 of the Immigrationand Nationality Act not within the scope of c. above (coverage must be restricted to certain emergency services during the five-year period beginning on the date the alien was granted eligibility); or e. Is an alien who is not lawfully admitted ."f.or permanent residence or otherwise permanently residing in the United States ·under color of law (coverage must be restricted to certain emergency services). P.L. 99-603 (section 201) f. Is an alien who is not lawfully admitted for permanent residence or otherwise permanently· residing in the United States under color or law. TN No, il ... 4 1 •. . JAN l - . 1992 Supersedeh/ J Approval Date M_AY__ . _ Effective Date TN No. · J_ - _ HCFA ID: 7984E ,. ATTACHMENT 2.6-A ··- - --·-···-·-· ··~· - -'-~· - ... ----·· -.:.,.,_ - Page 3a OMB" No~-: --··0938- - -- ·-----~ StateiTerritory: Puerto Rico Citation ·Condition or Requirement 42 CFR ~~ 5. a. Is not an inmate of a public institution. Public l/3l~ institutions-do not include medical institutions, /~ot/ intermediate care facilities, or publicly operated community residences that serve_no more than 16 residents, or certain child care institutions. ti 3 (p. 1 oot.J 42 CFR ~§~100-8 b. Is not a patient under _age 65 in an institution 1905(a) of the for mental dise9ses except as an inpatient under_ Act age 22 receiving active treatment in an accredited psychiatric facility or program~ /At .Not applicable with respect t_o individuals under age 22 in psychiatric facilities or programs. such services_are not provided under the plan. 42 CFR 433.145 6. Is required, as a condition of eligibility, to assign ··:: ..·... . -_,. 1912 of the his or her own rights, or the rights of any other person Act who is eligible for Medicaid and on whose behalf the _ individual has legal authority·to execute an assignment, to medical support and payments for _medical care from - any third party. (Medical support is defineq as support specified as being for medical care by a court or administrative order.) · I lI TN No. CJ~-~ OCT 1 4 1992 31Jt 1 1992 Supersedes Approval Date ------Effective Date TN No. Ne~ HCFA ID: 7985E {. Revision: HCFA-PM-91- 8 (MB) ATTACHMENT 2.6-A Octoberl991 · ··· ------·-·Page·-3 a.-1--·~~--. -··--·------~-·--·-·- -~ ,. OMB No.: 0938- State/Territory: Puerto Rico Citation Condition or Requirement An app l t cant; or r·ecip,i.ent must also cooperate in establ·ishing the paternity of any eligible child and in obtaining medical support and payments for himself or herself and any other person who is eligible for Medicaid and on whose behalf the individual can make an assignment; except that individuals described in §1902(l)(l)(A) of the Social Security Act (pregnant women and women in the post-partum period) are exempt from these requirements involving paternity and obtaining support. Any individual may be exempt from the cooperation requirements by demonstrating good ~ause for refusing to cooperate. · An applicant or recipient must als~ .cooperate in identifying any third party who may be liable to pay for care that is covered under the State plan and providing· . information.to assist in pursuing these third parties. Any individual may be exempt from the cooperation requirements by demonstrating good cause for refusing to cooperate. {_! A~signment of rights i~ automatic because of State law. f36·9DI 4 2 CF R 4-J.a .-!M;-0:. 7~ Is required, as a condition of eligibility, to furnish his/her social security account number (or numbers, if he/she has more than one number). TN No. CJ2-Ff OCT 14 1992 JUL 1 1992 Supersedes Approval Date Effective Date No.· TN NeWi .r HCFA ID: 7985E { . \. ATTACHMENT 2.6-A .. . -·-·- ----.- ., .. _. ...,. __ ,...... :------·- ..... Pag.e ... ~~ . OMB No.: 0938-· Puerto Rico State/Territory: Citation Condition or Requirement 1906 of the Act 10. Is required to apply for enrollment in an employer• based cost-effective group health plan, if such plan is available to the individual. Enrollment is a condition of eligibility except for the individual who is unable to enroll on his/her own behalf (failure of a· parent to enroll a child does not affect a child's eligibility). TN No. 9a.-B: 4 1992 JUL 1 1992 Supersect~11 , Approval Date OCT l Effective Date TN No. 1~ewi HCFA ID: .79BSE .. Revision.: HCFA-PM-91- 4 (BPD) ATTACHMENT 2.6-A AUGUST 1991 · --·- .. ,.PAg.~·Li.-~. ~·-····-- OFFICIAL- OMB No. : 09'3"8·::.-···--·-·.,,..--~---- Territory: Puerto Rico Citation Condition or Requirement 42 CFR 436.403 4. Is a resident of the State, regardless of whether. 1902(b) of the or not the individual maintains the residence Act permanently or maintains it at a fixed address. State has interstate residency agreement with the following States: State has. open agreement(s). Not applicable; no residency requirement. 42.CFR 436.1004 5. a. Is not an inmate of a public institution. 1905(a) . Public institutions do not include medical of the Act. institutions, intermediate care facilities, or publicly operated community residences that serve no more than 16 residents, or certain child care institutions. - b. Is not a patient under age:65 in an institution / ..· · for mental diseases except as an inpatient under ( age 22 receiving active treatment in an accredite psychiatric facility or program. __x_ Not applicable with respect to individuals under age 22 in psychiatric facilities or programs. Such services are not provided unde the plan. TN No. 7lf? -t:f' Supersedes Approval Date MAY 1 1Q92 Effective Date ,IAN 1 - 1992 TN No. 8'8 ... } HCFA ID: 7984E - ( .'· ... {.. ... ·. ~.: .·. .... Citation· ··Condition or Requirement . . · .. ·::;.r?i.;. .· 42:crR 433.145 6,· Is required, as a condition of eligibility, to and· 436.604 assign rights to medical support and to payment for <;:·; ~ .:::.;_/~;:/~y\.. : ',_: · .. ·1912 Of the Adt· · medical care fr'o·m any third ·party, to cooperate ·in ·ob.taining such support. and . payments, .. and to . · . ·. \/:._i~~'.i~;::::..• ·-.-.~~~-i . ·: ... · .. ooopexat.e ·in identifyinq and ·providing informati·on ·to ~ • ' • •'I •'• o• assist in .pursuing arty liable third· party. The · =.. ~: ~~~.~'.;; ;."<:':. .. ,_. assignment of rights obtained from an applicant or .\.'x.>· recipient. is effectiVI\' on:ly::for services that a.t'.e · · .. . ..~ . . .. ., . . . ·:t;:\:~~t!\(·t:·,:·~~~-~(···.~ :·. ··:' :: .. . ;'· reimbti:i:;sed by Medicaid. ·Th~· requirements ·of 42 CFR 433 .146 .through ·433 .148 ·are ·m~t. . I ;~i:,~_:.:,;,~{ . ~ ··~·. ·,'f' .' :. 1·,· ...... ·.: .. ·TN.No. 'J;"l-Jl .MAY 1 Effective Date 1..; Superse~es · -0 l Approval Date 1992 JAN 1992 TN No. 3 a_- _ HCFA ID: 7984E :r· ... ------ Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 OFFICIAL ~r~·-·- ~"':"'.'.. "'"f... ~-... ~-··~~.,~~·~-=-,. ,,, .. : ...... ,.-- ..... - ... 0,...- .. ------\ · Revisforr:-·---"HCF-Ac--PM--9-l- 4- __ .{BPD)__ ATTACHMENT 2. 6-A AUGUST_ 1991 - -:-·---~- --· ·~ --.,.... • ..,_, ...._ D.,• ...,._~-~-··- -· ----Page_s ~~---- . _ OMB No.: - 0938::---~---- Territory: Puerto Rico Citation . Condition or Requirement .. ·_ B. Post-Eligibility Treatment of Institutionalized Individuals 42.CFR 436.832 Required deductions. The following amounts are deducted from gross income when r= !-.'· r.. computing the application of an individual_'s or couple's income to the cost of institutional care: 1. Personal Needs Allowance. $ $60 · Couple _ $30 . Individual rI 2. For maintenance of the non-institutionalized spouse· l only. $ 32. 00 i 11 3. ~or3~~~0irrstituti~nalized children, each family member. j l 4. Amounts for incurred medical expenses not subject to I payment by a third party. I a. Health insurance premiums, deductibles and coinsurance charges. b. Necessary medical or remedial {:are not covered under the Medicaid plan. (Reasonable limits-on amounts arE described in- Supplement 2 to ATTACHMENT 2.6-A). I 5. An amount for maintenance of a single individual's home 1 for not 'longer than 6 months, if a physician has l certified he or she is likely to return home within _tha· f period. - Yes. Amount for maintenance of home$~~~~~- -,· ~J -X-,.;.. No • I I [ i: ~'l I J ff TN No. Gj'Jl-;;L'.: - v l 4nM Supersed~ I Approval Date M/\1 - - •vw. Effective Date JAN 1 - . 7992 TN No. - ~8 - _ _ HCFA ID: 7984E ',~ :r ( OFFICIAL ·. ·Revision: HCFA-PM-93-5 (MB) ATTACHMENT 2.6-A ·MAY- 19.93·,- .... .l~i'lg~ 7- ·· .. ,._, _; ·~-----,-·-·· ···.····· _ . Territory: Puerto Rico citation Condition or Requirement 1902(1) of 6. Benefits paid under AB, APTD, or AABD to blind or the·Act disabled individuals during the. initial- 2 months in which.the individuals receive care in a hospital, SNF, or ICF if the individuals are allowed to retain the penefits under agreement with the facility: or during a temporary stay in a hospital, SNF, or ICF, if it is determined that the individuals' stay is not likely to exceed 3 months and they must continue to maintain a home to which they may return upon leaving the institution. c. Financial Eligibility - Categorically and Medically Needy, Qualified Medicare Beneficiaries, Qualified Disabled and Working Individuals, and Specified Low• Income Medicare Beneficiaries l. categorically Needy Income Levels a. For categorically needy groups other than those specified in items C.l.b. and c. below, the financial eligibility income levels for the related cash assistance programs are ~~ applied. -;:~~~ b. Supplement 1 to ATTACHMENT 2.6 specifles the income eligibility levels for the following groups of individuals with incomes related to the Federal income poverty line: r I ·:r ./ . [ TN No.. ') 3-S JAN 11 1994 Supersedes Approval Date~~~~~~~ Effective Date _J_U_L~l~--·_19_~_3~ TN No. q l-.;l_ . · .... · . . . . Uff/CfAL ~~"'~~.,,s_,.,..{MBL .. z: -:-·· :·~·····~, •• ..:._ ·-~·?~~~~~-~:.•::'.'.. ~. , : '····~-_,.. r '~ ·:·· · ..-::· . · . ·.Te.rr ~ tory: · Pu ert.o . Rico . ·... · .. ;, \ · ... ·'--;:-"~-...... :...-...,.-"'------'------:------··:· ; · '.·\. Cit~t~O~·''· Condition.or Requirement ... \:.:;: .': .. · ·.. ··· .::: .. · .' ' . ··· ·~:- -·.. .. '.,,z:F~·>L· ·: .., - , , . t;.~;·~i·:-~;;~ l'; ~ • :·. • • . ,.\· .. '·. Optional categorically -needy.groups of aged and·disabled. individuals covered under ' . ' the .provisions Qf·. section· · · · : 1902 (a) (10) ·(A) {ii} {-X}.-ofth!'! Act; ·.:a~d ...· . (iii) Optional. groups of qualified Medicare . ' . ~ . benefici~ries under the·Frovisions of·se~tion : .· 1902(a) (lO'(E) (i).. of the .A.ct.· · (iv) .opt~onal groups of specified 10W-in6ome Me4icare benef£ciaries under the provisions of · section 1902(a) (10).(.E)'(ii.i) of the Act. For optional groups of qlialified· disabled and . ~· working' individuals; the financi:al eligibility income ~ 1evel.s specified in section 1905(s) of ·the ·Act are ~~ applied~ i . ! ) Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 f Transmittal No: 93-5 TN No~. 93...,.s ·supersedes 'f .Approval Date _J_A.._N_1_1_19_9 __4_ ·Eff.ective Date _J_U., L_l_-_ 19_93,.:___ TN .No. ~J.-~ ·OFFICIAL Revisiofl: HCFA-PM-93-5 (MB) ATTACHMENT 2.6-A MAY.1993 ·Page -- 9 · --- -· ··--·------~~------·----- Territory: Puerto Rico Citation Condition or Requirement 1902(a) (10), 2. Income and Resources Methodologies - 1902(a)(l7), Categorically Needy and Medically Needy, and 1902 (r) p) Qualified Medicare Beneficiaries, Qualified of the Act Disabled and Working Individuals, and Specified Low• Income Medicare Beneficiaries. a. AFDC-related individuals (except for poverty level related pregnant women, infants, and children). (1} In determining countable income and resources for AFDC-related individuals, the following methods are used: X (a) The methods under the State's approved AFDC plan only; or -- (b) The methods under the State's approved AFDC plan and/or any more liberal methods described in Supplement 5 to ATTACHMENT 2.6-A. (2) In determining relative financial ~ responsibility, the agency considers only the ~-~... -· income of spouses living in the same household as available to spouses and the income of ., parents as available to children living with !, parents under the _children become 21. / ~ ~! I' I ~:' I f !I I! ~ ~ I' I ,'( TN No. . Cf3-S JAN 11 1994 JUL 1 - 1993 i Supersedes Approval Date Effective Date !1 i TN No. 9J.-d.,_ l i I OFFl:C·IAL HCFA-PM-91-4 (BPO) ATTACHMENT 2.6-A AUGUST ·· 19 91 ·· · · · · -··. ······-~~ .. -- _,_~.. ., _..~ . Paqe 10 OMB ... No~: 0939·..:··- ... ,- ..... ·- Territory: Puerto Rico Citation Condition or Requirement · b. Aged,.Blind and Disabled Individuals. For aged, blind, and disabled individuals, including aged and disabled individuals covered under section 1902(a)(lO)(A)(ii)(X) of the Act, the agency uses the followingmethods for'determininq countable income and resources :. · _x_(lJ The methods of the appropriate cash assistance program only;· or __ (2) The methods of the appropriate cash assistance program and/or more liberal methods described in Supplement 5 to ATTACHMENT 2.6-A. ._ __ . TN No. 9#2-(?l::; Supersedes J Approval Date _M...'6_~_1 __ 1_9B2__ Effective Date _J_A_N_l _-_19_9_2 TN No. gg- _ HCFA ID: 7984E r ~- .. ·. :;Rev·i~ion:. _ HCfA-PM,-92-1. (MB} OFFICIAL ATTACHMENT2. 6-A . ~ ::<~::: .· . .)l'EBRUl\.R".{ 1992 · . ·· : ...... Page 12 ~ ..JF.:!.~.m,·.~:1:·~ 1.-.· • · .•::·:."·.:; ·_. ·: --:.. - :.·· • ·.~•t ?':u·, :;· ,:,(!.i·F-'i~,,... -.i--· ~· :··· ul -~-- -· ,.,.~ .. ~ -- .. ;,--,..~----.r.~-..-··· -:· .. ·.~"'.- .....-~·~··· ~-- .•. -~ .._ . -~·:-i-'1· . ..··---·· -·· ••.• ,. . ~··• .. .. , .... ,: .. · .. ,·,.· .. '· .: ·. ·. ··STATE PLAN UNDERTITLE XIX OF THE SOCI.1\L SECURITY'ACT 1;""•.:· • ·i .... . :.... ~.-·: .. ,•\...... ·' . ··Tert"itory: .PUERTO RICO. FINANOIAL ELIGIBILITY }:;,;~~it~i:n~:) \ 'Groups cover~d .. ·.. >::,,,. ·...... \~.~:~.;',!~!:~-~-~ >~)fi:~.~:: :1~;;~~-- ... '. ·.·· •, T?e agen9y c9ntinues to treat women eligible: under. the . provisions of · · . sections. 1902(aH10) ·t;if the Act as ~1;;;;:::::c · :'; , -.'. · · · eligibl~, .without regard to ·any changes·· in income of ·the family, of which she· is a member, for the ·~·~:~i~~~~;i\h:\~}·.:~-~::::: '.·: ... ;,..;·,·:·. ··f!O-day p~rson. after .he,r .pregnancy • I ' ; ,,.• ends and any remaining days in the month·in.which the 60th.day. falls • '.!~~;~~·>;,~,t -, ! •t.. t;.·... ~ ,. :.. • • •.· •• • • :: • • ... ·. ·~ ···.· . ..' ··= ..·.:: ...... ~. :·:. ,. . .. ·; .• ·:····· ... . ·~ . ~. ·...... ·~· . . -·~ NOT APPLICABLE Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-4 , . fJC7 a TN No. q :J-9: supersedes ·Approval Date--~~~~--'-~- Effe9tive Date ~J_U_L~l_-_1_9_92~- TN No: ~.1-.,.a. ·OfflCIAl Revision: HCFA-PM-91-8 (MB) ATTACHMENT 2.6-A October 1991 Page 12b OMB~·No-:·:-----...· ---·---~·,,.,,-·~.--.. .. - ... · - --·- ,. · · State/Territory: PUERTO RICO Citation Condition or Requirement 1902(u) (h) COBRA Continuation Beneficiaries . of the Act In determining countable income for COBRA continuation beneficiaries, the following disregards are applied: The disregards of the SSI program; The agency uses methodologies for treatment of income more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to Attachment 2.6-A. NOTE: For COBRA continuation beneficiaries specified at 1902{u) (4·), costs incurred from medical care or for any other type of remedial care shall not be taken into account in determining income, except as provided l.n section 1612 ( b) ( 4) ( B) {ii) . NOT APPLICABLE TN No. fJJ ... g _ OCT 14 1992 Supersede~fi Approval Date E.ffective DateJUL------1 1992 TN No. l!l'tle'Wt HCFA ID: 7985E :r ( nt::VJ..l:IJ.OU: n,_..,,,,- ....'l-;l!.4 -.L \ l'LD I .... ""'·· ... .:-...... 1992 . •, . FEBRUARY ·. Cll'JAI . . Page 130 STATE l?LAN VNDERTITLE Of'lcJ'!'~~~~AL ·s~c~IT~ ACT - -~------·T;r~;i.t~~i~ .. ,._,, -PUE°RTO .. :Rico·~-~--·~·----··-- .. - . , ,_ ·-· - --· ·~ . ,,,·,. ~· .. ,..,....,~,,.,.,..,,_.;,.,,.._,_,,_.:--·--~· Citation(.s} Groups cove~e(i \ l' ../. . ' ~:·• ~' -to;' 1902(e) (6) f. In· aet:ermffilrig the Lncorae of. ·pregnant women~ of the Act the.ag~ncy disregards-all increases in income . throughout the pregnancy and· ;the pc:>stpartum. periO.d • . NOT APPLICABLE Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-4 TN No. q ;). - If" (J'C f' 8 1s:n r1111L 1 · supersed)\J Appro~~l Date------Effective Date ~ - 1992 TN No. ew ·. ' OFFICIAL ATTACHMENT 2.6-A Page: 14·~-·-·-~- : ·-- .··. Puerto R i c.o Territory: citation Condition or Requirement 1905(p)(l)(C) and g. For qualified Medicare benefic_iaries covered under (D) and 1902(r)(2) section 1902(a)(lO)(E)(i) of the Act, the agency uses of theAct the following methods for treatment of income and resources-- The methods used under the SSI program. The methods used under SSI program and/or more liberal methods described in Supplements 5 and 6 of ATTACHMENT 2.6-A. 190S(s) of the h. For qualified disabled and working individuals Act covered under sec::tion 1902(a)(10){E)(ii) of the Act, the agency uses the methods under the SSI program for treatment of income and resources. 1902 (a){10) (E) {iii) i. For specified low-income Medicare beneficiaries of the Act covered under section 1902(a)(10)(E)(iii) of the Act, the agency uses the same methods as in g. for QMBs. Not Applicable .. TN No. Cf3-S JAN 11 1994 JUL· 1 - 1993 Supersedes Approval Date Effective Date , TN No. . q;i-Y. Revision: HCFA-PM-91-8 (MB) ATTACHMENT 2.6-A . October. .19~l · Page 14a State/Territory: -~r'--"""uE~Rro"--"R~1co'-L--_o_MB_""'No_· ·~-_-·-·~~,--"--offi:C.1At···-·· Citation Condition or Requirement a. Medically Needy (Continued) 1903(f)(2) of the Act (3) If countabl~ income exceeds the MNIL standard, the agency deductis spenddown payments made to the State by the individual. ,( NOT APPLICABLE OCT 14 1992 TN No. 9~-8 Approval Date Effective Date.JUL 1 1992 Superse~~'•*' TN No. ~nJ. HCFA ID: 7985E/ ,,. OFFlC·IAL (BPD) ATTACHMENT 2.6-A Page 15 OMB-No;·:·,··0938,-, ..... _ .... ,,, "·- ·Territory: Puerto Rico -Citation Condition or Requirement 1902(k) of the 3. Medicaid Qualifying Trusts. Act In the case of a Medicaid qualifying trust described in section 1902(k)(2) of the Act, the amount from the trust that is deemed available to the individual who established the trust (or whose spouse established the trust) is the maximum amount that the trustee(s) is permitted under the trust to distribute to the individual. This amount is deemed available to the individual, whether or not the distribution.is actually made. This provision does not apply to any trust or initial trust decree established before April 7, 1986 ,· solely for the benefit of a mentally retarded individual who r.esides in an intermediate care 'facility for the mentally retarded . . '. LI The agency does not count the funds in a trust as described above in any instance wherethe State . ,_,--.::· ..... determines that it would work an undue hardship • Supplement 4 to ATTACHMENT 2.6-A specifies wnat . ···· cons t Lt.uties an undue hardship • J TN No. 9/l-,;i, superse~ Approval Date MAY 1 Effective· DateJAN 1.;. 1992 TN No .. ew . HCFA ID: 7984E Revision: HCFA-PM-91:-8 (MB) October 19 91 State/Territory: PUERTO Rl.CO Citation Condition or Requirement 4.b. Categorically Needy - Section 1902(f) States Continued 1903(f)(2) of (6) Spenddown payments made to the State by the Act the inc;lividual. NOTE: FFP will be reduced to the extent a State is paid a spenddown payment by the individual. NOT APPLICABLE TN No. tf.~.-f!: Approval Date _O_C_T_1_4_1_9S2 · Effective Dat;UL 1 1992 Supersedes HCFA ID: 7985E/ ~ TN ": 1New OFFICIAL (BPD) ATTACHMENT 2.6-A ~r~'~'~'"":,~,_.,,.~h··~-,-~:~~-~i-~_n i~ 4 =-·-·-·~~::s~:..~~ ~. "··-··- ···-··· '-· ~--.-- -. ·-··:--·" -·-·--~ ·---· .,., .. , - Page 16 .... OMB .. No;: --·0938""··-···-·--···-~-~ ·Territory: Puerto Rico Citation Condition or Requirement 1902 (a) ( 10,) (C) 4. Medically Needy Income Levels .ot: the Act a. Medically needy income levels (MNILs) are based on family size. b. The MNIL does not diminish by family size. c. The MNIL at least equals the amount of the highest income standards used on or after January 1, 1966, to dete~mine eligibility under the cash assistance programs related to the States covered medically needy groups or groups of individuals. Supplement 1 to ATTACHMENT 2.6-A specifies the MNILs for all covered med Lce Lt y needy groups. 42.CFR 436.831 5. Handling of Excess Income - Spend-down for Medically Needy . . a. Income in excess of the MNIL is considered available for payment of medical care and services. The Medicaid a3ency measures available income for a period of ne month(s) (not to exceed six months) ~o determine the amount of excess countable income applicable to the cost of medical care and services. I! TN No. Superse Date MAY 1 19Ell . Effective Dat4ii1AN l - 1992 TN No. HCFA ID: 7984E ( Revision: HCFA-PM..,91- 4 (BPD) ( . AUGUST 1991 ·· Territory: Puerto Rico Citation Condition or Requirement b. If countable income exceeds the MNIL standard, the agency deducts the following incurred expenses in the following order: (i) Health insurance premiums, deductibles and co-insurance charges. (ii) Expenses for necessary medical and remedial care not included in the plan. (iii) Expenses for necessary medical and remedial care included in the plan. Reasonable limits on amounts of expenses· deduct~d from income under (b}(i) and (ii) above are listed below. · TN No • 9,g - qz... JAN .t - 1992 Superse'N Approval Date MAY 1 Effective Date~~------~-- TN No. ew HCFA ID: 7984E '<(',.. . · .. '·. ~ .'.· '=.:->·;:<":. · . .-_-.: ...-- :. ·. .': Citation -Condition or Requirement Incurred expenses that are subject to_ ~;g~ { ~). { 1 7 ) Pf the payment py. a third party are not ~educted,· . ,~'.~i~~~~~ • unless the expenses arEf subject to payment··.by a ...... ·: ... -th,ird party that ·.rs a publicly funded· program (other than .Medicaid) of a State or local ·· gov~rnment. ~i::;:;::'' .• :, ... •. ~·. The ~gency·elects _not to deduct. incurred· .. . expenses th'at are paid ·by· a ·tni·rct-pa:i;.-ty·that · is a: program fµnded_. l)y a S~ate or. local . . government under its section 1902(£) opt~on• . f S,B1~:rn::~.~ · 6·. Resource ·.stand_~rd _:.. 'categ_oricaJ,ly Needy -, a. -Except. as. specffied in· item ·c.:6.b. below, the ...... ·! ::--:.~: «, : •••• '. • • • resourpe ·standards are the same' as those in the . ·, ...... ~:: : .. . .. -..•. .':. .~ ·:·:1 .d.·.. ... :: •If • . :. :. : .: .' ! ~ : .. • .: • : .. related. ca~h as~~stanc~ program • . ~;;~j~:~:ti~'.1~/r.::;~~{'+''": "• .,....._. . \ " : • • • • ~ • I •: . • ' . :·: ·: ··>. . . : ... . . -- ·I •. .: ..... :··' ..... ·· .. , ,•.' ' ..... .-: ·.. ··, •' TN. No. 9;;1.-;g;· · MAY 1 19'll Superse~ Approval O'ate . Effective Date .IAN..a. 1 - 1992 TN No. -new - ··. HCFA IDi 7994E Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 '~ ATTACHMENT ·2•6-A Page 19 ·. ' . . 'OMB-' Citation condition or Requirement !:, . 1902(a) (-10) (C) 7·. Re.source. Standard. - Medically Needy. ·of the Act a. The resource standard does not· diminish by· . famlly size.. . .. ;' ..: .... .:. .. ::· .: .... ·...... , . '; b , Resource standard equal. ·to r-~he · higflest · res<;iurc~ ·_:·7:-· .,,_ .... standard. used in the cash as·s~stanee pro.grams related ... ~ .... to the covered medically needy· gJ;"oUps,. · . . ·r ·., TN xo , 94""Jl M'LY l WZ : supers'edWt •• iPJ;iroval Date -"----• Effective oateJAN 1 - 1992 TN ?fo. IJlew · HCFA ID: 7984E Transmittal No: 13-006 Effective Date: 01/01/2014 Partia! Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-2 . . . . Revision: HCFA-PM-91-a {MB) OFFICIAL ATTACHMENT 2.6-A ~}-~_,._;~f-.:')-;·oil~~r'.~ ...... : ..,_-;o.,...... _-:'r.<:""':'"·~--,~.~-· October-,,19·9-l·-·--··-. · ·-····-·-·-- - - ... --·-·:· ------··-·~--- .....- - ...- -~·-·~·- .... --_.. .. ···--·--- .... R~.9-.~u 20·~~-~·--·-- 0MB No.: State/Territory: PUERTO RICO Citation Condit'ion or Requirement 1905(p)(l) 5. h. For Qualified Medicare beneficiaries covered under (C) and (D) and section 1902(a)(10)(E)(i) of the Act the agency uses 1902(r)(2) of the following methods for treatment of resources: the Act · The methods of the SSI program only·. The methods of the SSI program and/or mor.e liberal methods as described in Supplement 8b to ATTACHMENT 2.6-A. 1905(s) of the i. For qualified d Ls'ab Led and working individuals Act covered under. section 1902(a)(10)(E)(ii) of the Act, the agency uses SSI program methods for the treatment of r~sources. 1902{u) of the j. For COBRA continuation beneficiaries, the agency uses Act the following methods for treatment of resources: The methods of the ssr program only. More restrictiv~ methods applied under section 1902(f) of the Act as described in Supplement 5 to Attachme~t 2.6-A. NOT APPLICABLE QUALIFIED MEDICARE BENEFICIARiES ARE NOT COVERD. t i TN No, t/~-fJ' JUL 1 1992 Supersedes Approval Date OCT 14 1992 Effective Date ------TN-No. 9;..-~ ,. HCFA ID: 7985E ·( Revision: HCFA-PM-91~8 (MB) ATTACHMENT 2.6-A -· .. -······- ··- · Oc cobe r 1991 ·---~·------···'-·-··- . Page 20a ·····--·-~-·-oMB~No';·:~----~--.--~-·-~----;---~-···-- State/Territory: PUE RTO RICO Citation Condition or Requirement 6. Resource Standard Categorically Needy a. 1!02(f) States. (except as specified under items 6.c. and d. below) for aged, blind and disabled individuals: Same as SSI resource.standards. NOT APPLICABLE More restrictive. The resour.ce standards for other individuals are the same as those in the related cash assistance program. b. Non-1902(f) States (except as specified under items 6.c. and d. below) The resource standards are the same as those in the related cash assistance program. Supplement 8 to ATTACHMENT 2.6-A specifies for 1902(f) States the categorically needy resource levels for all .covered categorically needy groups. i I ,tit, I ! l j TN No. q{)..-9 Supersedes · Approval DatJlCT 14 1992 Effective DateJUL 1 1992 I TN No. Newi I · HCFA ID: 7985E ~- l I ! ... ~.R~vision: HCFA-PM.:93-s (MB) . ATXAC~NT 2.6-A ~~~~~;i".~~'°:"i;~":"":,~·r:~;--;--·.,...,....:.,,."7'"_""_· .-. -.--.,~-.- .. ~:-.'-~···--·:··-- -··' -.·-··- -·---- · · -~---~·__,..__ .. , ... ----·Page· 21- ----"-· --- .... - MAY 1993 Territory: Citation Condition or Requirement 1905(p)(l)(D) and 8. Resource Standard - Qualified Medicare (p) (2) (B) and Beneficiaries a~d Specified Low-Income Medicare . 1902(a) (10) (E) (iii) Beneficiaries of .the Act For qualified Medicare beneficiaries and specified low~income Medicare beneficiaries covered under sections 1902(a)(10)(E)(i) and 1902(a)(10)(E)(iii) 'of the Act, the resource standard is twice the SSI resource standard. 1905(s} ofthe 9. Resource Standard - Qualified Disabled and Ac::t Working Individuals For qualified disabled a~d working individuals covered under section 1902(a)(lO(E)(ii) of the Act, the resource standard is twice the SSI resource fi\ltandard. Not Applicable TN No. (J.3-5 JAN 11 1994 Supersedes Approval Date -----~- Effective Date _J_U_L_l_-_19_93__ TN Na. qa-a. ATTACHMENT 2.6-A . Pag~ __ 42~L t OMB No.: i State/Territory:~~~~~-P_U_E_R_T_O~R_I_C_O~~~~~~~~~ Citation Condition or Requirement 1902(u) of the 9.1 For COBRA continuation beneficiaries, the resource Act standard is: _Twice the SSI resource standard for an indi v Ldua'L, More restric.ti ve standard as applied under section 1902(f) of the Act as described in Supplement 8 to Attachment 2.6-A. NOT APPLICABLE I I TN No. 9£--8' 1 Supersedes. Approval Date OCT 1 4 1992 Effective Date JUL 19S2 TN No. Ne~. HCFA ID: 7985E OFFl·CIAL '"ilevision: HCFA-PM-93-5 (MB). MAY 1993 · Territory: Puerto Rico citation Condition or Requirement 10. Excess Resources - Categorically Needy and Medically Needy, Qualified Medicare Beneficiaries, Qualified Disabled and Working Individuals, and Specified Low• Income Medicare Beneficiaries Any excess resources make the individual ineligible. 42. CFR 11. Effective Date of Eligibility - Categorically 436.901 and Medically Needy, Qualified Medicare Beneficiaries, Qualified Disabled and Working Individuals, and specified Low-Income Medicare Beneficiaries. a. Groups other than qualified Medicare beneficiaries (i) For the prospective period-- Coverage is available for the full month if the . following individuals are eligible at any time during the month. ~Aged, blind, disabled. ~AFDC-related. coverage is available only for the period during the month for which the following individuals meet the eligibility requirements • .. Aged,.blind, disabled. AFDC-related. TN No.. 93-s JAN 11 1994 · JUL 1 - 1993 Supersedes Approval Date Effective Date TN No. q;J,_-J,, . Revisl.~n: HCFAcPM-92d (MB). · · O.Ff lCIAl. ATTACHMENT 2. 6-A . FEBRUARY 1992 . Page 23 ~f~R~·~~.,.;" " ~,.,!,...';~.:.-,.~ .. ~ ..... ~··..:..~.-··-·-~·~•~~.,..,..~~.,-.,~-~ .. --~·-"·'~---:--~-~·-·--- , ;'. ·· · .. · : · · . STATE PLAN.' UNDER TITLE XIX OF . THE SOCIAL SECURITY ACT .(. >?~~·.: '.·/·.'. », :: • -, •• •• : •• !.err~tory: · .. ·PUERTO RICO -, :..' ·/ ·~·. :·.. .. ··1_. ~ ~ >~·:_ _~ ; .~·~ r ·. . -. .. : ·=· ... ·.:.:·:·;_;· ·.· , ·.. :::....;..-...,..:.· ··; ...... _. __,_....__"'""- __ .,._ _ __....._F INANCIAL ELIGIBILITY.-..;~~;;.;;;;.;;.;;... ._ _ :~..;;~x;~;;lf~ ~~~;~~.~·.c.~ .). :· .._ .·: -.. Condition or Requirement ·. . :~i:: . .". . ·:.. ·::: . . . ~ ..· . . (ii'). For the r~troacti ve·· period-- coverage. is availa:ble'· for three months _l?efo;e the date· of application · i~· .t;he f~ll.o~ing · iµ~ividuals· u-e eligible. · ,hged; blind~·. disable.d. . . . 'l AFOC"""r.elated • Cov~rage is a,va'ilµ.ble beginning the first day 9f the third mon~h before the date of application if the ~c;illow'ing· indivi<,l.uals would··have :been eligible at. 'any· time . during that mcipth_, had they applied. x _Aged~ ·blind; disab'ied. ..... ,. ·~ .. ·: ·'" · x «, :: -· • .AFoco::.rsrat~d.-~· ---· . \ •-! ·: ,' ·.r - : . t .. ' .. 0 : l '. 1 ' ' .::.. :·:.: .· ._;, : · ...... : . . ·:· c: .. ·. ...... Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 -. Transmittal No: 92-4 f TN No; 12-f . JUL 1- 1992 Supersedes q Approval Date O·Ci S 1992 .Effective Date ·TN No. . ;2..:.. ,i.. ------. . _. _.,000, .. ,.,~,. ", .. • "" • o • o • .... , ••O•O- .... ••·~~~'l~•••rJ• .. ~.,. ~··:~o• .. lo•• ,.4, ·:~~1•; o•o•••<•o•o •••• • .... , ... • ,,, •., .... ,.-"*'••• ...... ,_..::_, •• O••-•" ... ~ ••,•00 '""" ·•o••• •:\r"f*o·•Y• ': ' '''"'''~'' ...... _.~ ,. .. -:•"O'•••""HO..,o•w .. oo" •••• ATTAC1{1'fENT 2.6-A ... --Page...,..,24-~.---··,·~-~~· OMB No.: 0938- Territory: Puerto Citation Condition or Requirement 1902(e)(8) and b. For qualified Medicare beneficiarie~ defined in 1905(a) of the section 1905(p)(l) of the Act, coverage is Act available beginning with the first day of the month after the month in which the individual is first determined to .be a qualified Medicare beneficiary under section 1905(p)(l). The determination is valid for-- LI 12 months LI 6 months LI ~months (no less than 6 months and no more than 12 months). Not Applicable ···:S ·- ' . - ~\ Approval Date MAY 1 18Jfl Effective Date JAN l - 1992 HCFA ID: 7984E ,,;,. OfflClAl {BPD) SUPPLEMENT 1 TOATTACHMENT 2.6-A · ·· -· ..- -.-- .. ·-- ..... ,_ .. ··---Page-··1-- ...... - ...... , .. _ .. _...... --- .. ·-----· .. ·-~ OMB No.: 0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Territory: Puerto Rico INCOME ELIGIBILITY LEVELS A. CATEGORICALLY NEEDY Payment Standards for 0 A A, AB APTD And AFDC FAMILY SIZE PAYMENT 1 $32. 2 64. 3 96. 4 128~ 5 160. 7 to 12 add. on $32. 192 13 add on $24 I , II I TN No. 94.- ::2 Supersedes / Approval DatJIAY 1 199'Z Effective. Date JAN t - 1992 Tn No. 8'8'- HCFA ID: 7984E ..... ( QfflC\Al ~-~-. -~- ---······ -·--Rev.ision.:--.-HCFA-::PM-:-91:- .. .4 .... _(_~QL____ SUPPLEMENT 1 TO ATTACHMENT 2. ?-A . AUGUST 19 91 ...... •. ----·-······--page . 4--,... . . -·--·-----:-" OMB No. : 09"38- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Territory: Puerto Ri.co INCOME ELIGIBILITY LEVELS {Continued) 3. Aged and Disabled Individuals The levels for determining income eligibility for groups of aged and disabled individuals under the provisions of section 1902(m)(4) of the Act are as follows: Based on· __ percent of the official Federal income pov~rty level: Family Size Income Level l $ 2 $ 3 $ 4 $ .5 $ Not Applicable TN No. 9tfl -c;z;; 1 18(1 1 1992 . supersedes Approval Date MAY . Effective Date------~JAN Tn No. 68- I HCFA ID: 7984E [ ~. j . f ( t ,. i rI DF!ICIAl ---~pageSUPPLEMENT s 1· TO ~------···ATTACHMENT 2.6-A • ·oMB.No.: .0938- STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Territory: ------...,.-----~----~/ INCOME ELIGIBILITY LEVELS (Continued) C. OPTIONAL GROUP OF_QUALIFIED MEDICARE BENEFICIARIES The levels for determining income eligibility for qualified Medicare beneficiaries under the provisions of sections 1905(p)(2)(A) and 1905(p)(4) of the Act ar~ bas~d on-~ percent of the official Federal poverty level. · D. OPTIONAL GROUP OF SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES -·~ The. levels for determining income eligibility for. f?pecified low-income Medicare beneficiaries under the provisions of sections l905(p}(2}(A) and 1905(p)(4) of the Act are based on percent of the official Federal ·poverty level. -t- -- ,,. / TN No, '}3-5 J Supersedes Approval Date AN 1 1 1994 Effective Date JUL 1 - 1993 TN No.· qi-a *U.S. G.P.0.:1993-342-239:80080 !.'! SUPPLEMENT 1 TO ATTACHMENT 2.6-A ·. r."'~~'f . ·------·~:-··-· O.. - .. -·· ·----··--·-·· ...... ·-·-·---· ...... ···- .._ -·-··-·-- . --R~rnL~-~--~--~·~···---··~----·:---·-- ,.. . , TERRITORY: Puerto Rico INCOME LEVELS - MEDICALLY ~FEDY _X_ Applicable to all group __ Applicable to: (1) (2) (3) Family Net income level Net inc-0me level Size protected for for persons living Maintenance in rural areas I I Urban only Ix I Urban & rural 1 $ 4,800.00 $ 2 $ 5,940.00 $ 3 $ 7,080.00 $ 4 $ 8,220.00 $ , 5 $ 9 360.00 $ 6 $ 10 500.00 $ 7 $" 11 640.00 $ 8 $ 12 780.00 $ 9 $ 13 920.00 $ 10 $ 15 060.00 $ For each additional person add: 1,140.00 $ $ TN No • 'l!E..:3 JUL 1- 1992 Supersedes Approval Date --'D"""C..,_T:::...... > { ( -if; ~e.r P [\!\ 8lo--'Z.O l....~K '61 t-1 _) lo. Revision: HCFA-AT-85-3 (B!RC). SUPPLEMENT j TO ATTACHMENT 2. 6-A FEBRUARY 1985 - state: 'PAYMENT STANDARDS FOR FAMILY SIZE PAYMENT ·~:., 1 $32 2 64 3 96 4 128 5 160 6 192 7 to 12 Add on $32.00 :13 on add $24 NOTE~ Adult and children categories ha.ve the same payment standards. TU Bo. 8'S-L JUN. 1 9 1986 supersedes Approval Date ----- Effective Date JUL. 1 1985 TB !lo. ~2-7 • HCPA ID: 0004P/0102A -- - ., , .. i ) Revision: HCFA-PM-87-4 (BERC) SUPPLEMENT 2 TO ATTACHMENT 2.6-A MARCH 1987 OHB No.: 0938-0193 ~ Territory: Puerto Rico N/A REASONABLE LIMITS OU AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UDDER MEDICAID ~, \ ~ . . ·~ TN Mo. .&:ie= / . L Supersedes Approval Date _ Effective Date 1.1/1 /cf·~ )--~' TN No. _££'~ c; HCF.A ID:' 2004Pl0021P (WJ1-S ~efll A/tM.~ r JA/'~;H!i:. ).eqe./s.). . Revisio.n: HCFA-PM-92 -1 FEBRUARY 1992 STA~ PLAN UNDER TITLE XIX OF THE ·SOCIAL SECURITY ACT .•• '·-· t'• ·Territory~~;~ P_u_ER_T_o R_r_c_o__ •.. ~··----~------ -· ~ J.~ •••• . . · 5. · Age~ .and'Dis~bl~d Individuals. and Qualified Medicare Beneficiari's · ., . . . . ·. : Sarne as resource levels under sections 1612 and 1613 of.the Act. Sarne as mediqally ~eedy resource levels (appl~cable only if State. has a medically needy program). NOT APPLICABLE Transmittal No: 13-006 Effective Date: 01/01/2014 Partial Supersedes: Approval Date: 12/24/2014 Transmittal No: 92-4 TN No. . j j-lf · OCT 8 1992 JUL 1-·1S~ superse~ s: Approval Date·_._ ...... Ef.fective Date __ __,.. _ TN No.• -~ew . I •n ••I•••' •1• ••.-r:--:-:~.:,i::.~.::.·.: •··:~' ,._,.,~ ••r::-~~~.••,~-~~ ....:,:.~.i;:'.-•::""'-. 10">·- .. --·• .. ••_ .. ,.,, ...... -:-~•.,•··•w~:·"'~'' .. -- ...... _..,,._._ ..... ,_.~-~~~·:;-.,.-..- ... :-,.. .. , ..... T"";..,... .. ••••• ··~ •••••••Hu•t ·..: ...... : r•- •1 .... w ,,..,. • •. !:;:.• ::~·: ·:··~ ·.•• . <. Revision: HCFA- CMS (BPD) SUPPLEMENT 3 TO ATTACHMENT 2.6-A August 2001 Page4 .c:> OMB No.: 0938 - Territory: Puerto Rico RESOURCE LEVELS (Continued) B. MEDICALLY NEEDY ..lL Applicable to all groups, regardless of family size. For each eligible family unit, $2,500 will be considered as the sole resource level. -, .. _./ TN No. 01-1 { Supersedes Approval Date Effective Date· ---- Tn No. 92-2 HCFA ID: 7984E jff ·_ () L - ' (J l A . ·- ...... _ ... , ~- .. -... NOV 2 7 2001 r -_,...,"". ---·--' - I -- pprova Date ~ 111"1Al"'c:0 rl o e Tr-.1 J ... 6:\ ">------. q..~. 7.·'· '""'~-r:.c.c~,-.1.! .. _· '"-J-..,. Um O 12001 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Territory: Puerto Rico CONSIDERATION OF MEDICAID QUALIFYING TRUSTS--UNDUE HARDSHIP 1902(k) of the The following criteria will be used to determine Act, P.L. ~9-272 whether the agency will not count the funds in (Section 9506) a trust as specified in ATTACHMENT 2.6-A, section C.3., because it would work.an undue hardship for categorically and medically needy. individuals: - '~ ·,, ..... ,., : -:· .~-~ ·"'' ... _ ..· .. Undue Hardship is not a consideration. I I( I i I I ' j. l . . I lf i I Approval Date MAY 1 1992 Effective Date JAN· t - 1992: HCFA ID: 7984E ~ f OFFlCIAL Revision :--~~HCFA-PM,...91-4--(.BP..DL._~ . SUPPLEMENT 5 to ATTACHMENT 2.6-A It AUGUST 19 9 l . -···-· ····-Page~ l·~-·=·-·~~~---·.,,,·~--~- . · ( ' OMB No. : 0938- . . . ~.-~-"--~----~---~~ STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Territory=~~-P_u_e_r_t_o~_R_i_c_o~~~~~~~~ MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902{r){2) OF THE ACT . ·----·-.-· ··------·-·· -~ Not Applicable ~TN~No-.-.-~~':..2~--~;;;z;--~~~~~-u-~v~1~1-9~=-~~~~~~~~~.~--• Supersed"_ . Approval Date"""' Effective Date JAN 1- 199 Tn No. -e"'. 'WWf HCFA ID: 7984E .;,,. ai 6 to ATTACHMENT 2.6-A STATE PLAN UNDER TITLE XIX-OF THE SOCIAL SECURITY ACT Territory:~_P_u_e_r~t_o~R_i_.c_o~~~~~~~~~ MORE LIBERAL METHODS OF TREATING RESOURCES UNDER SECTION l902(r) (2·) OF THE ACT - - ·--=- r: - . Not Applicable TN No. 11/>:f Superse Approval Date Ef(ective Date JAN 1 • 1992 Tn No. HCFA ID: 7984E Revision: Supplement 8A to ATTACHMENT 2.5-A December 2013 Page 1 STATE PL.AN UNDER TlTU: XIX OF IHE SOCtAL SECURITY ACT STATE/ TEISRITORY: COMMONWEALTH OF PUERTO RICO LESS RESTRICTIVE!YtnHQQ$ QEJRi;ATH"JG INCOME UNDER SFCTION 1902 (r)(2} OF THE ACT r i Citation{s) Provfsion(s) .... .,~.-.,.,,.-.. ~,--~------~---~-~- ·---·· ~---~~---~~~~~------,- 42 cm 436.320 For the Medically Needy Aged, Blind, and Disabled, Puerto Rko will 42 CFR 436.321 disregard countable earned and unearnf!d Income equal to I h(? 42 CFR436.322 difference between the medtcallv needy income level standard for the appropriate family size"', and the Income limits described hi the chart dlspla ed below, 42 CFR436.320 For the Medi;~ilv i\Jeeiiv Agi:;~ca-ii~~;;;~-a~!ri51;-;I;f~~ft-he-~rno~~~"th~~ 42 CFR436.321 which an individual's Medfcarg Part B pn~mium is reduced through 42 CFR 4-35.:;i22 enrollment in a Med I care Advantage Pla11 is disregarded from Income. - -·-······--·------· ··-- .... ----·········--·· --·· ··-··-----·------ "'As defined in Supplement 1 to Attachment 2.6~A, Page 6 -··-- ·------·-'·'--'--··------~ Household size Monthly Income Limit "'*' 1 $BOO 2 ------~19-()Q ------3 $1,200 ~-~--~--~~- -- . -~-~-~-~c-•~~c"~---~--•cc ------'--'----'--'------j 4 $1,400 s $1,60_0 _ !-- ·····------·-· ···------§ ----- ·------~--.------_-2._!.!_?Q_O ---- 1-- . ------~------·· 7 -----··------·------$2,000 ----~---- [ 8 $2.200 Each Addltlonal Addiiional $200 *'" Net inconrn ltmtts. · Tr<-111snllttal No.: PR~l.6~0001 Effe-ctive Dat~: July- 1, 2016 JULY 26, 2016 Supersedes TN No.~ 13~005"8 Approval Date: ' . 01/17/2008 Supplement 8b to Attachment 2.6 A Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Agency: COMMONWEALTH OF PUERTO RICO LESS RESTRICTIVE METHODS OF TREATING RESOURCES UNDER SECTION 1902 (r)(2) OF THE ACT Citation (s) Provision (s) For medically needy aged, blind and disabled individuals Puerto Rico will disregard the difference between $I 0,000 and the medically needy 1902(r)(2) of the Act resource standard. TN No. NEW Supersedes Approval ~-R· 0 ·5 -~ Effective Date _O_C_T_O_l_Z_oo_J TN No. 07-011 Offl&\AL Revision: HCFA-PM-91-8 (MB) SUP-PLEMENT 11 TO ATTACHMENT 2.6-A -· - --_. 9c.~ob_e r __ l, 9 9 1 Pagel -- ·--~-oMB--No·;:' ( State/Territory: PUERTO RICO Citation Condition or Requirement COST EFFECTIVENESS METHODOLOGY FOR COBRA CONTINUATION BENEFICIARIES 1902(u) of the . Premium payments are made by the agency only if Act. such payments are likely to be cost~eff~ctive. The agency specifies the guidelines used in determining cost effectiveness by selecting one of the following met.hods, -- _x_ The methodology_as described in SMM section 3598. Another cost-effective methodology as _described below. I I I! TN. No. 9J"l- 8" Supers el\) Approval Date OCT 1 ~ 1992 Effective Date JUL 1 1992 - TN No. e-, HCFA ID: 7985E Medicaid Eligibility State Name:jPuerto Rico OMB Control Number: 09~~f1{~~ . Transmittal Number: PR - 17 - 0001 Expiration date: I 0/31/2014 .:;•;,: :_:--' 1902(e)(14) 42 CFR 435.603 ~ The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent • 42 CFR 435.603. In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: 0 The pregnant woman is counted just as herself. 0 The pregnant woman is counted as herself, plus one. @The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @Current monthly household income and family size 0 Projected annual household income and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: D Include a prorated portion ofa reasonably predictable increase in future income and/or family size. D Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CPR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435 .603( d), Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. CYes @No TN: 17-0001 Approval Date: 12/15/2017 Effective Date: 07/01/2017 PUERTO RICO 510 Medicaid Eligibility ~ The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: "::".~•:'Hi @Age 19 QAge 19, or in the case of full-time students, age 21 PRA Disclosure Statement ·1lt~tIB:l¥h; Ac~ording to the Paperwork Reducti?n Act of 1995, no persons are. r~quired t~ respond t.o a ~ollection of inform~tion unl~ss it disBjt~~K~jj~ valid OMB control number. The valid OMB control number for this information collection is 093 8-1148. The time required to COl?JHl~te'{ this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing:~.at~J~::··.'.: resources, gather the data needed, and complete and review the information collection. If you have comments concerning the acc~"'"1''~:f' the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Cl._ ce j~g;:~·&. Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. '.)l} ;' v.2oir4oif1s .. ;{V~·:_~;·~-:i'. ... ~ - .. f~ ;:?;·' jMu:I ·t~~H: Kir w:i I:W~t# m~~i'. TN: 17-0001 Approval Date: 12/15/2017 Effective Date: 07/01/2017 PUERTO RICO SlO ATTACHMENT 1 TO MAGI FORM 810 SUPERSEDING PAGES OF STATE PLAN MATERIAL Transmittal Number: State: PR-17-0001 Puerto Rico PAGE NUMBER OF THE PLAN PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT: SECTION OR ATTACHMENT (If Applicable): SPA PR-17-0001, MAGI Form SlO NEW and its Attachments, will be insert as Supplement 12 to Attaclunent 2.6-A Notwithstanding any other provisions of the Puerto Rico in the Medicaid State Plan. Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment (SPA) MAGI Form S 10 - MAGI Income PR-17-0001 will apply to all MAGI-Based Eligibility Methodology and Attachments: Groups covered under Puerto Rico's Medicaid State Plan. • Attachment 1: Superseding Pages of State Plan Material. The MAGI financial methodologies set forth in 42 CFR • Attachment 2: MAGI-Based § 435.603 apply to everyone, except those individuals Income Methodologies. described at 42 CFR § 435.603G) for whom MAGI-Based • Attaclunent 3: CMS approved Methods do not apply. 1902(e) waiver, letter dated August 5, 2014. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-Based Eligibility Groups. ATTACHMENT 2 TO MAGI FORM S10 MAGI-BASED INCOME METHODOLOGIES Transmittal Number: State: PR-17-0001 Puerto Rico Household Composition • In determining Household Composition, the following provisions are not applicable: 42 CFR §435.603(f)(l), (f)(2), (f)(4), and (f)(5). • Household Composition for all individuals is defined in accordance with 42 CFR §435.603(£)(3). It means that the Household Composition is established using the "Rules for individuals who neither file a tax return nor are claimed as a tax dependent.11 Household Income • In determining Household Income, the following provisions are not applicable: 42 CFR §435.603(d)(2), (d)(3), and (d)(4). • Household Income for all individuals is defined in accordance with 42 CFR §435.603(d)(l) and (e), It means that the Household Income is established using the 11MAGI-based "Household income-(1) General rule'' and income.11 Household Income Disregard • Puerto Rico has elected in the S14T Income Standards - Territories state plan page to use the Local Poverty Level (LPL), which is the Puerto Rico Poverty Level (PRPL), instead of the Federal Poverty Level (FPL). As noted on the Sl4T, "Wherever FPL is referenced in the other sections of the State Plan; it means the Local Poverty Level. 11 • In determining the Medicaid eligibility of an individual using MAGI-Based Income, the Medicaid Program deducts from household income an amount equivalent to 5 percentage points of the PRPL for the applicable family size, consistent with 42 CFR §435.603(d)(4). The deduction is only to determine the eligibility of an individual for medical assistance under the MAGI-Based Eligibility Group with the highest income standard in the applicable Title of the Social Security Act, but not to determine eligibility for a particular eligibility group. Household Income - CurrentMonthly Income • The "Current monthly income" generally means the month of application. Household Income - Cash Support • The election on S 10 page 1, to consider actually available cash support exceeding nominal amounts for individuals described in 42 CPR §435.603(f)(2)(i), is not applicable. • Income received from absent parents, relatives, or non-relatives from inside or outside of Puerto Rico is not counted towards an individual's T-MAGI income calculation. Since household composition under T-MAGI is based on the non-filer rules, the only income that may be counted is the income from other family members in the household constructed using the non-filer rules. This includes the individual, spouse if living with the individual, children under age 19, in accordance with 42 CFR §435.603(f)(3). Household Income - Child'sIncome • Living with One or Both Parent A child's income will not count toward the household MAGI if: i. The child is in the household with one or both parent and 11. The child's income does not meet the IRS tax filing thresholds (i.e., when counting earned and/or unearned income) adjusted for the Puerto Rico standard of living. See Supplement 1 to Attachment 2 - "Child Income Threshold Test" - to determine if the child's income will count. • Living with Other Caretaker Relative or Unrelated Adult If a child is not living with one or both parent, child's income counts as a regular member for any household in which the child is a member, including the household in which the child is the member being evaluated. [As an example, a child who is living with a grandmother (caretaker relative) and siblings.] SUPPLEMENT 1 TO ATTACHMENT 2 MAGI FORM SlO: MAGI-BASED INCOME METHODOLOGIES "CHILD INCOME THRESHOLD TEST" When a child lives with at least one parent, determine whether the Child's MAGI Income counts for households in which it is included by performing the following steps. If, after step 6 the Child Income is marked as "Countable" then his/her income is to be included in the household income. Use test values from Child Income Tax Threshold table for the appropriate year. For any calendar year use the prior Tax Year, e.g. - when evaluating a case in 2017, use lookup values from Tax Year 2016 in table. 1 Calculate Unearned Income (U) Add: Taxable Interest (1, 2) Ordinary dividends Capital gains distributions Unemployment compensation Taxable social security benefits (3) Pensions Annuities Distribution of unearned income from a trust 2 Calculate Earned Income (E) Add: Salaries/Wages/ Tips Professional fees Net self-employment income Taxable scholarship and fellowship grants 3 Calculate Gross Income (G) U+E 4 Determine (T) as the larger amount UIL between OR E (to max ofGL) +GI 5 Test U>UIL OR E>EIL OR G>T 6 Determine - Child Income is COUNTABLE IF step 5 is TRUE OTHERWISE IF step 5 is FALSE Child Income is NOT COUNT ABLE As an example: • For any calendar year Puerto Rico will use the prior Tax Year, e.g. - when evaluating a case in 2017, use lookup values from Tax Year 2016 in table of the IRS Publication 501, (For 2017, see https://www.irs.gov/pub/irs-pdf/p505.pdf). • For calendar year 2017, Puerto Rico will use the values as published for the IRS Publication 501 for Tax Year 2016. • For a household of 1 member the monthly PRPL is $459 as established in the MAGI Form S14T that it is part of the SPA PR-13-0006, which was approved by CMS on December 24, 2014. The annual PRPL is $5,508 since July. pt 2017. • For a household of 1 member, the monthly FPL for 2017 is $1,005 as published in the Federal Register on Tuesday, January 31, 2017, (82 Federal Register pages 8831-8832). The annual Federal Poverty Guidelines for the 48 Contiguous States and the District of Columbia is $12,060 for 2017, (12,060 / 12 = 1,005). • The annual PRPL to FPL conversion ratio for 2017 and for each year so on is calculated as follows: Calendar Year 2017: PRPL = $5,508 FPL= $12,060 Ratio= 5,508112,060 = 46% (applies to Tax Year 2016) • The monthly PRPL represents a 46% of the FPL (459 / 1,005 = 0.456). • The IRS Publication 501 for Tax Year 2016, Table 2 - 2016 Filing Requirements for Dependents on page 4, provides values for the formula as follows: UIL (Unearned Income Limit)= $1,050 - EIL (Earned Income Limit) = $6,300 - GI (Gross earned income Increment)= $350 - GL (Gross earned income Limit)= $5,950. • Applying the 46% to convert to the Puerto Rico levels results in: UIL (Unearned Income Limit)= $483 EIL (Earned Income Limit) = $2,898 - GI (Gross earned income Increment)= $161 - GL (Gross earned income Limit)= $2,737. Unearned Income Limit $483.00 (UIL) Earned Income Limit (EIL) $2,898.00 Gross earned income $161.00 Increment (GI) Gross earned income Limit $2,737.00 (GL) NOTES 1. Report all taxable interest. • Taxable interest should be as delivered to taxpayer on Forms 1099-INT, Forms 1099-0ID, or substitute statements. • Include interest from U.S. savings bonds series EE, H, HH, and I. 2. Exclude interest from series EE and I of U.S. savings bonds issued after 1989. 3. Effectively zero for children in income ranges eligible for Medicaid & CHIP. Child Income Tax Threshold Table Unearned Income Limit 9,999 9,999 9,999 (UIL) Earned Income Limit (EIL) 9,999 9,999 9,999 9,999 Gross earned income 9,999 9,999 9,999 9,999 Increment (GI) Gross earned income Limit 9,999 9,999 9,999 9,999 GL) During any calendar year, the prior Tax Year's threshold values will be used as the most recently available. The process for determining whether to count a child's income as described on the preceding page is based on IRS rules as found in Publication 501. The values to be used in the IRS formula will be adjusted for the Puerto Rico standard of living based on the ratio of the Puerto Rico Poverty Level (PRPL) to the Federal Poverty Level (FPL). This ratio will be calculated each calendar year based on the values for PRPL and FPL for that year and applied to the preceding tax year. At the start of any calendar year, if the up to-date values are not yet known, the most recent table available will be used. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Mary land 21244-1850 amERS tOR MEDICARE & M£DlCAIDSEl!VtC£S CENTER FOR MEDICAID & CHIP SJ:RVICES AUG 0 5 2014 Ricardo A. Colon Padilla, CPA Executive Director, Medicaid Program P.O. Box 70184 San Juan, Puerto Rico 00936-8184 Dear Commissioner Padilla: This letter is in response to Puerto Rico's request, dated June 25, 2014, to assist the Territory as it implements the Medicaid and Children's Health Insurance Program (CHIP) changes resulting from the Affordable Care Act. Under the authority of section 1902(e)(l4) of the Social Security Act, we are approving your request to temporarily enroll individuals who do not meet current MAGI income standards, but who would have been eligible under prior standards and methodologies while Puerto Rico conducts additional evaluation of the accuracy of the conversion of those prior standards to equivalent MAGI standards (the MAGI conversion) . This temporary enrollment will protect beneficiaries from adverse effects should Puerto Rico determine that the SIPP-based MAGI conversion did not accurately maintain equivalent eligibility standards in the aggregate in Puerto Rico. In your request, you explained that Puerto Rico will implement MAGI systematically in the MEDITI system and operationally through local eligibility offices. For a period of 6 months after MAGI implementation "go-live", Puerto Rico is approved to enroll in medical assistance, for a period of 12 months, new applicants and beneficiaries undergoing renewals who are found to have income above current MAGI income standards, but who would have been found to be eligible under the standards and methodologies in effect as of December 31, 2013. During the 6 month period described above, Puerto Rico will monitor the movement and potential movement of Medicaid recipients between Medicaid, CHIP and the Puerto Rico funded Commonwealth program. It will use the results of this evaluation to determine whether adjustment of the MAGI income standard is warranted through the submission of a SP A. We understand that this SP A could take the form of either a change in the MAGI income standard or a change to the local poverty level. We understand that Puerto Rico's objective, taking into account its recent expansion, is to maintain Medicaid eligibility enrollment in the aggregate. The Centers for Medicare & Medicaid Services (CMS) has determined that the authority granted in this letter is necessary to protect beneficiaries as the state completes the analysis necessary to move to a MAGI-based eligibility system. Accordingly, the authority is granted only to the extent to which Puerto Rico requires additional time to evaluate its MAGI income standards and is contingent upon regular updates from the state on the status of its data analysis and income conversion development. Page 2 =Ricardo Padilla The authority provided in this letter is subject to CMS receiving your written acknowledgement of this approval and acceptance of these new authorities within 30 days of the date of this letter. If you have questions regarding this award, please contact Stephanie Kaminsky, Senior Policy Advisor, Children and Adults Health Programs Group, Centers for Medicaid & CHIP Services, at (410) 786-4653. We look forward to our continuing work together to achieve successful implementation of the Affordable Care Act. er~~Sincerely, Director cc: Michael Melendez, Associate Regional Administrator, Region II { ··--··-·-·~~- Addendum to Supplement 9 to Attachment 2.6-A Page 8 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State: I Territory: Puerto Rico Transfer o_f Resources 1917 c of the Act For transfer of resources made on or after July 1, 1988 the State.is in compliance with provisions of 1917c of the A~t as amended .by the provisions of the Medicare Catastrophic Coverage Act of 1988, the Family Support Act of 1988 and the Omnfbus ... Reconci,liation Act of 1989. ,. .. AUG 2 8 1990 TN NO. Approval Date Supercedes APR O 1 1990 TN NO. tJe-uJ Effective Date OFFICIAL ATTACHMENT 3.1-A Pagel Stateff erritory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL· AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 1. Inpatient hospital services other than those provided in an institution for mental diseases. X Provided __ No limitations X With limitations* 2.a. Outpatient hospital services .. X Provided __ No limitations X With limitations* 2.b. Rural health clinic services and other ambulatory services furnished by a rural health clinic. X Provided __ No !imitations X With limitations" 2.c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCFA-Pub. 45-4). X Provided __ No limitations X With limitations* 2.d. Ambulatory services offered by a health center receiving funds under section 329, ~30, or 340 of the Public Health Services Act to a pregnant woman or individual under 18 years of age. X Provided __ No limitations X With limitations* 3. Other laboratory and x-ray services. X Provided __ No limitations X With limitations* t. *Description provided on attachment. \ \ \ \ TNNo. 03..-(')7)/!9 . MAR 0 5 2004 AUG 1 3 ·2003 Effective Date - ' Supersedes 'J . Approval Date ----- TNNo. Z.,....,.. 2- ., { Attachment 3.l.A Page?. STATE PLAN UNDER TITL}3 XIX OF THE SOCIAL SECURITY ACT Staie Agency Puerto Rico AMOUNT.JJURA'tIQl\!, ANO SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICAl,LY..NEEDY 4.a. Nursing facility services (other than services In an institution for mental diseases) for indivlduals 21 yeats of age or order. _P1·ovided ___N o Limitations _With Hmi~ati()t1s* .X. Not Provided 4.b. Eady and periodic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of'conditlons found. X Provided X No Limitations ~With Hmitations" 4.c. Family planning services and supplies for Individuals of'chlld-bearing age. X. Provided _No Llmitations X With limltatlons" 4.d. I) Face-to-Face Tobacco Cessation Coullscllng Services provided: X (i) By OI' under supervision of fl physlclan; X (ii) By any other health care professional who is legally authorized to funiiSh such services under State law Md who fs authorized to provide Medicaid coverable services other than tobacco cessation services; or (iii) Any other health care professional legally authorized to provide tobacco cessation services under State law and who is specifically designatedby tire Secretary in regulations.· (none are designated at this time) 2) Face-to-FaceTobaeco Cessation Couusellng Services fo1• Pregnant We1me11 Provided: .K No limitations With limltations" *Any benefit package that consists of less than four {4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12 momhperlod should be explained below. Please describe any limitations: 5;a. Physicians' services whether furnished in the office, the patient's home, a hospital; a nursing facility 01· elsewhere. :X Provided -~No Limitations .X With limitationa" 5.b. Medical and surgical services funrished by a dentist (in accordance with seotion 1905(a)(5)(B) of the Act). X Provided ._No Limitations .X. With limltations" · 6. Medical care and any other type of remedial care recognized under State law; furnished by licensed practitioners within the scope of their-practice as defined by State law. a; Podiatrists' services X Provided _No Limitations XWlth limitations" *Descripti911 provided on nttachment. JAN 2 8 2014 OCT O 1 2013 TN Nq. 13~004 Approval Datp Effective Date Supersedes TN No. 03~001A Attachment 3.l~A Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECUIUTY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGOR[CALLYNEEDY b. Optometrists' services ~ Provided D No limitation ~ With limitations" D Not Provided c. Chiropractors' services [2.?J Provided D No limitation [:gj With limitations" D Not Provided d. Other practitioners' services [8l Provided D No limitation ~ With Iimitatlons" D Not Provided 7. Home Health Services a. Intermittent or part-time nursing services provided by a home health agency or by a registered nurse when i10 home health agency exists in'the area. D Provided D No limitation D With limitations" ~Not Provided under the PRHIA Health Reform Plan b. Home health aide services provided by a home health agency. D Provided D No limitation 0 With limitations" ~Not Provided under the PRHIA Health Reform Plan c. Medical supplies, equipment, and appliances suitable for use in the home. 0 Provided DNo limitation 0 With limitations" [25J Not Provided under the PRHTA Health Reform Plan * Description provided on Attachment. Transmittal No.: 14-008 Effective Date: July 1, 2014 Supersedes TN No.: 03-001-A Approval Date: __,_\'Y_\-\-4\\(\_·'"-T~~'--\__,,__ _ l,_ ATTACHMENT 3.1-A Page 3a ('\t,~\t\t\\.j\ . State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORlCALL Y NEEDY d. Physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility. ___ Provided __ No limitations __ With limitations* X Not Provided under the PRHIA Health Reform Plan 8. Private duty nursing services. ___ Provided __ No limitations __ With limitations* X Not Provided *Description provided on attachment. '!': . AUG 1 3 2003 ::~J-fJ D/1'f prova! Date HAR 0 5 2004 Eftectrve Date ----- TNNo.~ · ATIACHMENT 3.1-A OFFICIAL Page4 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 9. Clinic services. X Provided ~_No limitations X With limitations" 10. Dental services. X Provided __ No limitations _x_ With limitations" 11. Physical therapy and related services. a. Physical therapy X Provided __ No limitations _ _:,X..::c._With limitations* b. Occupational therapy X Provided _ ___.,_X,,__No limitations __ With limitations* c. Services for individuals with speech, hearing, and language disorders (provided by or under the supervision of a speech pathologist or audiologist) X Provided X No limitations __ With limitations* "Description provided on attachment. TNNo.0 J 'CJYJ//1_ MAR O 5 2004 AUG 1 3 2003 Supersede~5' Approval Date Effective Date TN No. _. 3 ----- ATTACHMENT 3,1-A Page 5 STATE/TERRITORY: PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 12. . Prescribed drugs, dentures, and prosthetic devices: and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist. a. Prescribed drugs rZJ Provided 0 No limitation IZJ With limitations* 0 Not Provided b. Dentures D Provided D No limitation D With llmltations" ~ Not Provided c. Prosthetic devices cg] Provided D No limitation IZJ With limitations* D Not Provided d. Eyeglasses [Zl Provided D No limitation IZJ With limitations* D Not Provided (Provided based on EPSDT Guide) 13. Other diagnostic, screening, preventive, and rehabilitative services, i.e., other than those provided elsewhere in the plan. a. Diagnostic services IZ] Provided D No limitation [Z] With limitations* D Not Provided "Description provided on attachment. ------·-·--·----· ·- --- TN No.: _ Approval Date: 02/16/2016 Effective Date: January 1. 2016 Supersedes: 03-001-A ATTACHMENT 3.1-A Page 6 State/T erritory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY b. Screening services X Provided __ No limitations X With limitations* c. Preventive services X Provided ___. No limitations X With limitations* d. Rehabilitative services X · Provided __ No limitations -~x~· _With limitations" 14. Services for individuals age 65 or older in institutions for mental diseases. a. Inpatient hospital services. · X Provided X No limitations __ With limitations* (Based on medical necessity-Law 408) b. Skilled nursing facility services --~·Provided __ No limitations __ With limitations* X Not Provided c. Intermediate care facility services ___ .Provided __ No limitations __ With limitations* X Not Provided *Description provided on attaclunent. TN No. f>3--D 1)/A · MAR 0 5 2004 AUG 1 3 2003 Effective Date ~~~~~de8ZS .-';, Approval Date ----- ATTACHMENT 3 .• 1.,A Page 7 STATE/TERRITORY: PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 15. a. Intermedlate care facJlity services (other than such services in an institution for mental diseases) for persons determined; in accordance with section 1902(a)(31)(A). of the Act, to be in need of such care. 0 Provided D No llmltatlon 0 With Ilmltatfons" IZJ Not Provided p. Including such services In a public Institution (or distinct part thereof) for the mentally retarded or persons With related conditions. D Provided 0 No limitation D With hmitatlons" [8l Not Provided 16. Inpatient psychiatric facility services for individualsunder 22 years of age. ~ Provided ~ No llmltation D With limitations* D Not Provided (Based on Medical Necessity under Law 408) 17, Nurse-midwlfe services D Provided 0 No limitation D With limitations* ·~ Net Provided .18. Hospice care {In accordance with section 1905(0) of the Act). D Provided 0 No limitation [8] Not Provided ~ Provided D With limitations* In accordance with section 2302 ofthe Afforcfable Care Act *Description provided on attachment. TN No.: _1_4-~09}~---- Approval Date: JUL· 1 o 2014 Effective Date: April 1, 2014 Supersedes: 03-001-A { ATTACHMENT 3.1-A Page 8 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY · 19. Case management services and Tuberculosis related services a. Case management services as defined in, and to the group specified in, Supplement 1 to ATTACHMENT 3.1-A(in accordance with section 1905(a)(19) or section 1915(g) of the Act). --'X:..::...__Provided X With limitations" __ Not Provided b. Special tuberculosis (TB) related services under section 1902(z)(2)(F) of the Act. -~X~_Provided X With limitations" __ Not Provided 20. Extended services for pregnant women a. Pregnancy-related and postpartum services for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60u1 day fall. X Provided X Additional coverage ++ b. Services for any medical conditions that may complicate pregnancy. X Provided X Additional coverage ++ + + Attached is a description of increases in covered services beyond limitations for all groups described in this attachment and/or any additional services provided to pregnant women only. * Description provided on attachment. Postpartum and pregnancy-related services after the pregnancy ends are covered beyond the 60t11 day if medically needed. Services for any other medical conditions that may complicate pregnancy are provided without limitations. TNNo.l)j_...61)/'/4. HAR 0 5 2004 AUG 1 3 2003 Effective Date ~~~~~detlJ tj/ ,. Approval Date ----~ ATTACHMENT 3.1-A Page 8a State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 21. Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period by a qualified provider (in accordance with section 1920 of the Act). --~Provided __ No limitations __ With limitations* X Not Proyided 22. . Respiratory care services (in accordance with section 1902(e)(9)(A) through (C) of the Act). --~Provided __ No limitations __ With limitations* X Not Provided 23. Pediatric or family nurse practitioners' services. X Provided __ No limitations X With limitations" (According to our Health Plan coverage and state licensing laws - general nurse practitioners) "Description provided on attachment. TN No. ~ 3- {) 1J/ 7" ti,R O 5 2004 AUG 1 3 2003 Effective Date ----- Off\t\l\t ATTACHMENT 3.1-A Page 9 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 24. Any other medical care and any other type of'remedial care recognized under State law, specified by the Secretary. a. Transportation X Provided __ No limitations __L With limitations* b. Services of Christian Science nurses --~ Provided __ No limitations ___ With limitations* X Not Provided c. Care and services provided in Christian Science sanitoria ___ Provided __ No limitations __ With limitations* X Not Provided d. Nursing facility services for patients under 21 years of age. ___ Provided __ No limitations __ With limitations" X Not Provided e. Emergency hospital services X · Provided X No limitations __ With limitations" f. Personal care services in recipient's home, prescribed in accordance with a plan of treatment and provided by a qualified person under supervision of a registered nurse ___ Provided __ No limitations __ With limitations" X Not Provided "Description provided on attachment. TN No. 03 - . ~-,? . MAR 0 5 Z004 AUG 1 3 2003 Supersedes . . . _., . Approval Date _ Effective Daf~ TNNo. '?~-'_I!!!" ATTACHMENT 3.1-A OFFICIAL Page 10 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 25. Home and Community Care for Functionally Disabled Elderly Individuals, as defined, described and limited in Supplement 2 to Attachment 3.1-A, and Appendices A-G to Supplement 2 to Attachment 3.1-A. --- Provided No limitations __ With limitations* X Not Provided "Description provided on attachment. AUG 1 3 2003 Supersedes' $ ., _ Approval Date Effective Date ----- TNNo. '~ r--_- \ Attachment 3.1-A Page 10 a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Agency Puerto Rico MEDICAID PROGRAM: REQUIREMENTS RELATING TO COVERED OUTPATIENT DRUGS FOR THE CATEGORICALLY NEEDY 12.a. Prescribed Drugs: Description of Service Limitation Citation(s) Provision(s) 1935(d)(l) Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare - benefits under Patt A or Part B. 1927(d)(2) and 1935(d)(2) The Medicaid agency provides coverage for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid recipients, including full benefit dual eligible beneficiaries under the Medicare prescription Drug Benefit -Part D. 00 The following excluded drugs are covered: ("All" drugs categories covered under the drug class) D ("Some" drugs categories covered under the drug class D -List the covered common drug categories not individual drug products directly under the appropriate drug class) ("None" of the drugs under this drug class are covered) D 00 (a) agents when used for anorexia, weight loss, weight gain a1·e excluded as a general rule. Puerto Rico provides coverage of medically-necessary mental health drugs when used in · the treatment of anorexia according to the medical psychiatric practice accepted norms as reg uired for the diagnosis, prevention, and treatment of the mental health disease. D (b) agents when used to promote fertility D ( c) agents when used for cosmetic purposes or hair growth D (d) agents when used for the symptomatic relief of cough and colds TN No. 13-002 Approval Date JUN 2 0 2013 Effective Date January l, 2013 Supersedes TNNo. New Attachment 3.1-A Page 10 b STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Agency Puerto Rico MEDICAID PROGRAM: REQUIREMENTS RELATING TO COVERED OUTPATIENT DRUGS FOR THE CATEGORICALLY NEEDY 12.a. Prescribed Drugs: Description of Service Limitation Citation(s) Provision(s) !Bl · (e) prescription vitamins and mineral products are excluded as a general rule, except · preri~tal -vitamins and fluoride. Puerto Rico also covers some vitamins and. mineral products when there are prescribed, medically necessary, and used in the treatment of cancer, renal disease, or HIV/AIDS. ~ ·• (f) nonprescription drugs or over-the-counter (OTC) drugs are excluded as a general 1·ule. · Puerto Rico covers some OTC drugs (Non Sedating Antihistamines, Antihistamine, Respiratory Agent. Antiplatelet, and Topical Antimycotic products) when they are · presc1·i1bed and medically necessary according to the medical practice accepted norms as required for the diagnosis, prevention, and treatment of the disease .• D · (g) .covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee (see specific drug categories below) IE (h) barbiturates for non~dually eligible. Puerto Rico does not provide coverage for dual ~ligible i~dividuals With Medicare Part D, because of effective January l, 2013, Part D cov~rs these drugs when used in the treatment of epilepsy, cancer, or a chronic mental health disorder; except when these drugs are prescribed for a condition other than the -three covered by Part D and during Part D donut hole period if it is medically necessary. l:&I (i} benzodiazepines for non-dually eligible. Puerto Rico does not provide coverage for dual eligible individuals with Medicare Part D, because of effective January 1, 2013, · Part.J) covers all indications for these drugs; except for dually eligible without Part D and during Part D donut hole period if it is medically necessary. · ·oo ·u) smoking cessation drugs are excluded except for individuals under age 21 and for · pregriant·women when medically necessary and prescribed by a physician. In these : cases:the=plan covers prescription and non-prescription aids as indicated by a physician and without cost-sharing. 1NNo. 13~002 Approval Date .JUN 2O201~ffectiveDateJanuary1.2013 Supersedes 1NNo. New Attachment 3. 1.A Page 11 STATE PLANl)NDER TITLE XIX. OF THE SOCIAL SECURITY ACT State Agency: Puerto Rico Coverage Template for Freestanding Birth Center Services Attacluucnt.3.lA: Freestanding Jlirth Center Scnices 28. (i) Licensed 01· Otherwlse State-Approved Freestaudiug Birth Centers Provided: No limitations With limitations X None licensed or approved Please describe any limitations: 28. (ii) Licensed or Otherwise Stnte-Rceognlzed covered professionals providing services in the Freestanding Btrth Center Provided: No limitations With limltations (please describe below) X Not Applicable (there are no licensed 01· State approved Freestanding Birth Centers) . Please describe any Iimitatious: Please check aU that apply: a. Practitioners furnishing mandatory services described in another benefit category and otherwise coveted under the State plan (i.e., physicians and certified nurse midwives). b, Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum care in a freestanding birth Genter within the scope of practice under State law whose services are otherwise covered under 42 CFR 44-0.60 (e.g., lay midwives, certified professional midwives (CPMs)~ and any other type of licensed midwife).* c. Other health care professionals licensed or otherwise recognized by the State to provide these birth-attendant services (e.g., doulas, lactation consultant, etc.)." cl. *For (b) and (c) above, please list .and ide.ntifY. below each type of professional who will be pro.v1dh1g bitth center serviees: JAN 2 8 2014 OCT 0 12013, TN No~ Approval Date Effective Date r Supersedes 1> TNNo. NEW (r Description for Attachment 3.1-A Page 1 STATE PLAN UNDERTITL8 XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Description of Limitations General Limitations The following General Limitations and Exclusions apply to all services not just inpatient or outpatient services: a. Services rendered while the beneficiary is not covered. b. Services which result from illnesses or injuries not covered. c. Services resulting from automobile accidents which are covered by the Automobile Accident Compensation Fund (ACAA). d. Workman's compensation accidents covered by the "Fondo del Segura del Estado". e. Services covered by any other insurer or party that has the primary responsibility (other party liability). . f. Special nurses services for the convenience of the patient when it is not medically necessary. g. Hospitalization for services which can be rendered in an ambulatory setting. h. Admission of patients to hospitals for diagnostic purposes only. 1. Expenses for services and/or materials for the comfort of the patient, such as telephone, television, admission kit, etc. j. Services rendered by second generation family members of patient (parents, offspring, siblings, grandparents, grandchildren, spouse, etc.), k. Organ and tissue transplants, except as provided in Attachment 3 .1-E. I. Laboratories for which processing is not available in Puerto Rico and that have to be sent outside of Puerto Rico for processing. m. Treatments with the purpose of controlling weight (obesity or weight increase) solely for esthetic purposes. n. Sports Medicine, musical therapy, and natural medicine. o. Tuboplasties, vasovasectomies and any other procedures or services for the purpose of returning the ability to procreate, are excluded: Transmittal No.: 14-008 Effective Date: July 1, 2014 Supersedes TN No.: 03·001-A Approval Date: ~'?J-:~\\f\-T-- \"-" \~ \\-,...... _\ ~,~~~~~~ Description for Attachment 3 .1-A Page2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICA~ AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Description of Limitations p. Cosmetic surgery and treatment, solely to conect defects in the physical appearance, excluding also hospitalization, medical-surgical services and complications associated with this procedure, regardless of their medical justification . . q. Services, diagnostics tests and/or treatments ordered and/or provided by naruropaths, naturists, and iridologists. r. Mammoplasty or plastic reconstruction of the breast solely for cosmetic purposes. s. Ambulatory setting use of fetal monitor. t. Services, treatment or hospitalizations which arise from an induced abortion (not therapeutic). The following are considered induced abortions: DESCRIPTION 59840 Induced abortion, by dilation and curettage 59841 Induced abortion, by dilation and expulsion 59850 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines); 59851 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines); with dilation and curettage and/or evacuation. 59852 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines); with hysterectomy (failed intra• amniotic injection). Transmittal No.: 14-008 Effective Date: Supersedes TN No.: 03-001-A Approval Date: Description for Attachment 3.1-A STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Puerto Rico Page 3 AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Description of Limitations 59855 Induced abortion, by one or more vaginal suppositories {e.g., prostaglandin) with or without cervical dilation (e.g., laminaria), including hospital admission and visits, delivery of fetus and secundines. 59856 Induced abortion, by one or more vaginal suppositories (e.g., prostaglandin) with dilation and curettage and/or evacuation. 59857 Induced abortion, by one or more vaginal suppositories (e.g., prostaglandin) with hysterectomy (omitted medical expulsion). u. The Revetron drug. v. Services for epidural anesthesia. w. Somnography studies. x. Services which are not reasonable nor required according to the accepted standards of medical practice or services provided in excess of those normally required for the prevention, diagnosis, and treatment of a disease, injury or dysfunction of the organic system or pregnancy condition. y. Hemodialysis and/or peritoneal dialysis services are excluded from the Basic Coverage; but included in the Special Coverage. z. New and/or experimental procedures which have not been approved by the PRHIA for their inclusion as benefits in the basic and special coverage of the program. aa. Custodial, rest or convalescence services, in cases where the acute medical condition requiring in-patient care is under control or in irreversible terminal cases. bb, Expenses incurred in payments made by beneficiaries to participating providers that according to the terms of the program, the beneficiary was not supposed to pay. cc. Services ordered and/or rendered by non-participating providers, '·'" except in cases of emergencies/immediate need or previously authorized by the HCOs or MCO. dd, Neurological and cardiovascular surgery and related services are excluded from the Basic Coverage, but included in the Special Coverage. '1AR 0 5 nm~ AUG 1 3 2{)03 Supersedes Effective Date _ TN No. New Description for Attachment 3.1-A Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REM ED JAL CARE AND SERVICES PROVIDED TO THE CATEGORJCALLY NEEDY Description of Limitations ee. Services received outside of the territorial limits of the Commonwealth of Puerto Rico, except for emergency services received in the United States. ff. Expenses incurred for the treatment of conditions, resulting from procedures or benefits not covered under this Program. Maintenanfe prescriptions and required laboratories for the continuity of a stable health condition, as well as any emergencies which could result after the referred procedures, are covered. gg. Travel expenses, even when ordered by the primary care physician or participating provider are excluded. hh. Eyeglasses, lenses, and hearing aids are excluded, except for beneficiaries under age 21 when it is medically necessary and approved through a prior authorization process. ii. Acupuncture services are excluded. jj. Rent or purchase of wheelchair or any other vehicle (motor and/or electric) or expenses for the repair or alteration of these vehicles. kk. Procedures with the purpose of changing the sex of the beneflclarv. II. Treatment services for infertility and/or related to conception by artificial means. 1, Inpatient hospital services other than those provided in an institution for mental diseases Inpatient services are provided within coverageunder Health Heform Plan with limitations; Limitations oh inpatient services: o Bed in Semiprivate Room: Coverage will be available twenty four (24) hours per day, every day of the year. D Isolation Room: For medical reasons. e Specialized Diagnostic/ Treatment: Electrocardiograms, electroencephalograms, . arterial gases, and other specialtzed diagnostic and/or treatment testing that are available in the hospital facilities and which are required to be performed while the patient is hospitalized. ~-~---·---- 02/16/2016 TN No.: _ Approval Date: _ Effective Date: January 1. 2016 ( Supersedes: 03-001-A Description for Attachment 3.1-A ST ATE PLAN UNDER TITLE XIX OF THE SOCIAL SECUIUTY ACT State/Territory: Puerto Rico Page 5 AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORlCALL Y NEEDY Description of Limitations Limitations to inpatient services: • Short Term Rehabilitation Services: To hospitalized patients, including physical, occupational, and speech therapy. • Blood: Blood, plasma and their derivatives without limitations, to include irradiated and autologous blood; Monoclonal Factor IX per authorization of an certified hematologist; Antihemophyllic Factor with intermediate purity concentration (Factor VIII}; Antihemophyllical Monoclonal Type Factor per authorization of a certified hematologist and Protrombin Activated Complex (Autoflex and Feiba} per authorization of a certified hematologist. 2a. Outpatient services are provided within coverage under Health Reform Plan. 2b. Rural health clinic and ambulatory services provided are those categorized benefits under the Basic and Special Coverage of Health Reform Plan. 2c. Federally Qualified services and other ambulatory services are those categorized benefits under the Basic and Special Coverage of Health Reform Plan. MAR 0 5 20M AUG 1 3 2003 Supersedes 'l'f '3 Approval Date _ Effective Date _ TN No. _,. Description for Attachment 3.1-A Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY . 3. Other laboratory and X-ray services. Diagnostic blood tests and X-rays are covered, but the following special procedures and diagnostic tests are provided subject to benefits included under the plan's special coverage and medical necessity criteria: a. Computerized tomography. b. Magnetic Resonance Tests Imaging c. Cardiac catheterization d. Holter Tests e. Doppler Tests f Stress Tests g. Lithotripsy h. Electromyography · 1. Single Photon Emission Computerized - Tomography Test (SPECT) J. Ocular Plesthymography (OPG) k. Impedance Plesthymography 1. Other invasive and non-invasive cardiovascular, cerebrovascular, and neurosurgical procedures m. Nuclear Medicine tests n. Endoscopies for diagnostic purposes o. Genetic Studies. 4.c. Family Planning Services: The coverage benefits of the Puerto Rico Medicaid and CHIP Programs provide the following Family Planning Services: (i) education and counseling, (ii) pregnancy testing, (iii) infertility assessment, (iv) sterilization services in accordance with 42 CPR 441.200 subpart F, (v) laboratory services, (vi) at least one of every class and category of FDA (Food and Drug Administration) approved contraceptive medication, (vii) cost and insertion/removal of non-oral products, such as long acting reversible contraceptives (LARC), and (viii) other FDA approved contraceptive medications or methods when it is medically necessary and approved through a prior authorization or exception process. 5.a. Physician services in the patient's home are provided based on medical necessity. Transmittal No.: 15-001 Effective Date: April 1, 2015 Supersedes TN No.: 03-001-A Approval Date: SEP o 9 2015 Description for Attachment 3.1-A Page 7 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/ TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 5b. Medical and surgical services provided by dentist arc limited to the coverage services description on item (10). 6a. Podiatrist services are provided as remedial and incidental care rendered for attending special conditions under the Health Reform Plan's special coverage. 6b. 'Optometrist services are limited to vision evaluations and exams. 6c. Chiropractic services as determined medically necessary. Initial 15 sessions available without prior authorization. Additional 15 sessions require prior authorization. The treatment limit is combined with the limit for physical therapy. An individual may receive a total of 30 physical therapy and/or chiropractic sessions combined, Additional session beyond 30 is allowed with medical necessity and requires a prior authorization process. 6cl. Most types of practitioners are included, except for: alternative and sport medicine practitioners, iridologist, naturopaths, and cosmetic plastic surgeons. 7. Home Health Services No Ff P is claimed for Home Health Services. Transmittal No.: 14-008 Effective Date: July 1, 2014 Supersedes TN No.: 03-001-A Approval Date: \~-\\[\ \ \L'\ • v I Description for Attachment 3.l~A Page8 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/ TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDI CAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 9. Clinic servlces are provided according to and within to the State Plan coverage and complaint with 42 CFR 440.90, Including preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. The term includes the following services furnished to outpatients: (a) services furnished at the clinic by or under the direction of a physician or dentist and (b) services furnished outside the clinic, by clinic personnel under the direction of a physician, to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address. These clinics include Department of Health Clinics, Preven Clinics, Urgent Care Clinics, and Physician operated clinics. 10. Dental Services a. Dental Services for Children Under 21 Years of Age • All preventive and corrective dental services are covered for chifdren under age 21 (0-20) as indicated under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit requirement. • Orthodontic services to EPSDT eligible children as medically necessary to prevent and restore oral structures to health and function are covered. Orthodontic services for cosmetic purposes are not covered. • Pediatric Pulp Therapy (Pulpotomy) for children under age twenty-one (21) and stainless steel crowns for use in primary teeth following a Pediatric Pu! potomy. • Anesthesia services (subject to prior authorization} for a child with physical or mental handicaps in compliance with federal and local laws. Those special conditions includes, but not limited to, the followings: (a) autism, (b) severe retardation, (c) severe neurologic impairment, (d} significant attention deficit disorders with hyperactivity, (e) significant or severe mental disorders, (f) disable or unable to follow commands, and (g) any other condition that at the dentist professional judgment, impaired the required patient cooperation and feasibility to adequately perform the dental procedure. • Alf limitations may be exceeded based on medical necessity and approved through a prior authorization or exception process. Transmittal No.: PR-16-0003 Effective Date: July 1, 2016 Supersedes TN No.: 15-0001 Approval Date: _J_U_L_Y_o_s,_2_0_1_6 _ Description for Attachment 3.1-A Page 8a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/ TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLYNEEDY 10. Dental Services b. Dental Services for Members Age 21 and Over When It is Medically Necessary • Preventive dental services • Restorative dental services • One (1) comprehensive oral examination per year • One (1) Periodic oral examination every six (6) months • One (1) defined problem-limited oral exam • One {1} full series of intra-oral radiographies, including bitewings, every three (3) years • One (1) initial periapical intra-oral radiography • Up to five (5) additional perlaplcal/tntra-oral radiographies per year • One (1) single ftlm-bltewing radiography per year • One (1) two-film bltewings radiography per year • One (1) panoramic radiography every three (3) years • One. (1) cleanse every six (6) months • One (1) Prophylaxis, every six (6) months • Amalgam restoration • Resin restorations • Root canal • Palliative treatment • Oral surgery • Anesthesia services (subject to prior authorization) for beneficiaries with physical or mental handicaps in compliance with local law • All limitations may be exceeded based on medical necessity and approved through a prior authorization or exception process. Transmittal No.: PR-16-0003 Effective Date: July 1, 2016 Supersedes TN No.: NEW Approval Date: __ J_U_L_Y_o_s_,_2_0_16 _ Description for Attachment 3. l-A • Page 9 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Description of Limitation 11.a. Physical therapy and or chiropractor services as determined medically necessary. a. Initial 15 sessions available Without prior authorization. b. Additional 15 sessions require prior authorization. c. The treatment limit is combined with the limit for chiropractic care. d. An individual may receive a total of 30 physical therapy and/or chiropractic sessions combined. e. Additional session beyond 30 is allowed with medical necessity and requires a prior authorization process. 12.a. Prescribed drugs a. The PRHIA maintains a drug Formulary as the official formulary of drugs provided (.ll\ .... by the Health Reform Plan coverage, which contains most of the vast majority of therapeutic alterative categories available. b. A preferred drug list (PDL) is also maintained as a cost-effective utilization tool in rendering prescription benefits under the Health Reform Plan. c. The MCOs, MHijOs, and Direct Providers, that are contracted, agree to conduct the pharmacy billing and claims through the PRHIA's contracted Pharmacy Benefits Manager (PBM). . d. Under exceptional circumstances, a drug not included in the Formulary could be covered only through exceptional circumstances and procedure set forth below. Transmittal No.: 15-001 Effective Date: April l, 2015 •• Supersedes TN No.: 14-008 Approval Date: Description for Attachment 3 .1-A Page 9a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLYNEEDY Description of Limitation Limitations and Conditions of the Prescription Services a. Contraceptives drugs are covered under the Health Reform Plan for the treatment of menstrual dysfunction and for birth control purposes, as follows: (i) At least one of every class and category of FDA (Food and Drug Administration) approved contraceptive medication, (ii) At least one of every class and category of FDA approved contraceptive method, and (iii) Other FDA approved contraceptive medications or methods when it is medically necessary and approved through a prior authorization or exception process. b. Drugs required for the ambulatory or hospitalized treatment of diagnosed beneficiaries with AIDS or with an HIV positive factor are covered under the special coverage to include only antiretrovirals but excluding Protease inhibitors. The Protease inhibitors are not covered benefits financed under the Health Reform Plan, they are provided to Medicaid beneficiaries through coordination with the Regional Immunological Clinics of the Commonwealth Health Department's PASET Division. c. Immunosuppressant drugs for all transplant patients are covered only to the extent of maintenance treatment post-surgery to ensure the continuity of health stability of the beneficiary, as well as emergencies that may result after surgery (as transplants are not covered). d. New drugs for future inclusion are evaluated through an active process for revising on a continuous basis and evaluate the future inclusion of new medicines or the removal of medicines from the forrnulary. Considering the dynamic nature of this process, the PRHIA requires the inclusion or exclusion of medicines as changes and advances affect the standard practice for the treatment of conditions or developments of standard practices for the treatment of a condition or particular treatments. Transmittal No.: 15-001 Effective Date: April 1, 2015 Supersedes TN No.: NEW Approval Date: SEP o 9 2015 OFFICIAL Description for Attachment 3.1-A ST ATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Puerto Rico Page 10 AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Description of Limitations e. .No MCO,HCO, MBHO or providers can establish a different formulary from the one included in this addendum nor limit in any way the drugs and medications included in the formulary, f. In the event a beneficiary needs a drug or medicine that is not included in the formulary, the MCO, MBHO and providers will follow the usual pre-authorization procedure, to obtain drugs not included in the formulary, The providers hall have too btain the M CO's prior approval considering and documenting the particular merits of each case, which could include among others the following criteria: 1. A contraindication of drug that appears in the formulary. 2. Adverse reaction history to the drug that appears in the formulary. 3. Therapeutic failure to all available alternatives in the formulary, 4. Non-existence of alternative therapy in the formulary. g. For acute conditions, the amount of medication to be dispensed shall be limited to the needed therapy, but never for more than fifteen (15) days. When medically necessary, additional prescriptions are covered. . h. For chronic conditions (maintenance), the amountof the medication to be dispensed will be limited to a maximum of thirty (30) days. By prescribing physician recommendation, each prescription may be repeated up to six (6) times. When medically necessary, additional prescriptions are covered. 1. The indications on prescriptions issued for treatment of children with Special Health Cate Needs will indicate clearly the (30) day coverage therapy and that it can be repeated up to six ( 6) times. When medically necessary additional prescriptions will be covered. j. The use of bioequivalent medications and drugs approved by the FDA and local regulations is authorized, unless contraindicated for the beneficiary by the physician or dentist who prescribed the medication. k. The absence of bioequivalent medications in stock does not exonerate the Pharmacist from dispensing the medication nor does it entail the payment of additional surcharges by beneficiaries. Brand name drugs will be dispensed if the bioequivalent is not available at the pharmacy. I. All prescriptions shalt be filled and dispensed at a participating pharmacy properly licensed ,:,. under the laws of Puerto Rico freely chosen by the beneficiary. m. All prescriptions shall be dispensed contemporaneously with the date and hour that the beneficiary receives the prescription and requests that it be dispensed. 1NNo1) ~~1}5)//1 'MAR 0 $. 'lOU~ AUG 1 3 20D3 Effective Date ~~~edes~~ ..,...3 . Approval Date· ------Description for Attachment 3.1-A Page 11 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 12c. Prosthetic devices Those including all of the extremities of the body, the ocular therapeutic prosthesis and the segmentary instrumentation system trays for scoliosis surgery and fusion. 12d. Eyeglasses Eyeglasses or lenses are covered for Medicaid beneficiaries under age 21 when those are medically necessary. Eyeglasses or lenses benefit consist of a single or multi-focal lenses and one standard frame every 24 months. All type of lenses needs to be preauthorized, except for intraocular lenses. The repair or replacement of eyeglasses .within the 24-months term is covered when it is medically necessary and approved through a prior authorization process. 13a. Diagnostic Services General clinical laboratories, x-ravs, radiotherapy, pathology, pulmonary function and efectroencephalograms if necessary for treatment and convalescentcare are not subject to pre-authorizations by the PCP or HCO. For the special coverage diagnostic services described in item 3 above they are subject to necessity-criteria and pre-authorlzatlon. 13b. Screening Services Gynecological and Prostate Cancer screening according to accepted medical practice, including Papanicolaou test, mammographies, and P.S.A. as may be medically necessary and according to the age of the beneficiary. Accordingly to Puerto Rico's Health Policies the age of forty (40) years have been established as the initial date to commence cancer screening by mammography. Sigmoidoscopy for adults ages 50 and over with risk of colon cancer according to accepted medical practice. TN No.: _ Approval Date; 02/16/2016 Effective Date: January L 2016 Supersedes: 03-001-A Description for Attachment 3.1-A Page 12 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Description of Limitation 13c. Preventive services A comprehensive annual health evaluation for each beneficiary, to be performed by a qualified health professional including eye tests, hearing test, nutritional screening and evaluation, laboratories and all other exams· and diagnostic tests, and immunizations commensurate with age, gender, and physical condition of the beneficiary. This annual evaluation complements the services for children and adolescents to be provided accordingly with the periodicity schedules published by the American Academy of Pediatrics and EPSDT under Title XIX of the Medicaid program. Follow-up visits will be provided to all beneficiaries based on medical necessity criteria established by the State. All immunizations will be provided for children to age 21 and those necessary according to age, gender, and health condition of the beneficiary, including but not limited to influenza and pneumonia vaccines for beneficiaries over 65 years and vaccines for children and adults with high risk conditions such as pulmonary, renal, diabetes, and heart disease, among others. The Puerto Rico Department of Health provides vaccines to children ages 0-18 through the Children's Immunization Program. The coverage benefits of the Puerto · Rico Medicaid Program also include immunizations for Medicaid beneficiaries' ages 19-20. Each managed care organization (MCO), contracted by the State, will contract with immunization providers, duly certified by the Puerto Rico Department of Health, to provide the immunization services, Immunizations will be administered without any charge or deductibles. Counseling in physical health, oral health, and nutrition will be provided in accordance with the preventive service benefit to address the individual needs of the beneficiaries based on their health conditions, Transmittal No.: 15-002 Effective Date; Aprill, 2015 Supersedes TN No.: 03-001-A Approval Date: September 11, 101 S Description for Attachment 3.1-A Page 13 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY Description of Limitation 13d. Rehabilitative services The rehabilitative services provided are ambulatory. Except fol' physical therapy, all rehabilitative services such as: respiratory, occupational, and speech therapies services are unlimited, Physical therapy and/or chiropractic services (chiropractic manipulation sessions) as determined medically necessary. Initial 15 sessions available without prior authorization, Additional 15 sessions require prior authorization. The treatment limit is combined for chiropractic care and physical therapy. An individual may receive a total of 30 physical therapy and/or chiropractic sessions combined, Additional session beyond 30 is allowed with medical necessity and requires a prior authorization process, 19. Ambulatory treatment, hospitalization and other TB related services and case management are covered under the Special Coverage. 20. The extended services for pregnant women besides covering all pre-natal, delivery and post• partum care services, include all medical and obstetrical nursing services during the delivery; be it natural childbirth, cesarean section, or any other complication; hospitalization beyond minimum stay terms in case of maternity, high risk or secondary conditions to the pregnancy by medical recommendation. The minimum stay term for hospitalization for both mother and newborn will not be limited to less than 48 hours for normal vaginal delivery without complications and in the case of childbirth following cesarean section, the stay may not be limited to less than 96 hours for both mother and child. 24.a. · Transportation Limited to ambulance services in emergency cases, ground, maritime, and aerial ambulance services are covered within the territorial limits of Puerto Rico. No pre-authorization or pre• certification will be required in order to access these services, In general, the service shall be accessed either by beneficiary calling 9 I I or calling the local ambulance provider contracted and as instructed by the HCO and the MCO in the area. For non emergency transportation the Commonwealth follows the methods described in attachment3.1-D of this plan. Transmittal No.: 14-008 Effective Date: Supersedes TN No.: 03-001-A Approval Date: I ' I Revision: HCFA-PM-87-4 (BBRC) SUPPLEMENT 1 TO ATTACHMENT 3.1-A KARCH 1987 Page 1 OKB No.": 0939-0193 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY·ACT State/Territory: Puerto Rico CASE MANAGEMENT SERVICES ARE NOT PROVIDED A. Target Group: B. Areas of State in which services will be provided: L.. ./ Entire State. !__/Only in the following geographic areas (authority of section l91S(g)(l) of the Act is invoked to provide services less than Statewide: C. Comparability of Services !__/ Services are provided in accordance with section l902(a)(lO)(B) ~f the Act. L.J Services are not comparable in amount, duration. and scope. Authority of section 1915(g)(l) of the Act is invoked to provide services without regard to the requirements of section 1902(a)(10)(B) of the Act. D. Definition of Services: E. Qualification of Providers: TN No. - / Supersedes Effective Date TN !lo. ..!/~ HCFA ID: l040P/0016P Revision: HCFA-PM-87-4 (BIRC) SUPPLEMENT 1 TO ATTACHMENT 3.1-A KARCH 1987 Page 2 OKB No·.: 0939-0193 Puerto Rico OFFICIAL, State/Terl"l tory: r. The State assures that the provision of case management services will not restrict an individual's free choice of providers in.violation of section l902(a)(23) of the Act. l. Eligible recipients will have free choice of the providers of case management services. 2. Eligible recipients will have free choice of the providel."'s of other medical care under the plan. G. Payment for case management services under the plan does not duplicate payments made to public agencies or private entitles under other program aulhorities for this same purpose. TN No. JPG'"-; SupeC'sedcs Approval Date Effective Date TN No. lt/Uv- HCFA ID: 1040P/0016P Revision: HCFA-PM-86-20 {BERC) ATTACHMENT 3.1-B 8EPTEKBER 1986 Page 1 0.FFIC·IAL OMB Mo. 0938-0193 State/Terdtory: PUERTO RICO AMOUUT, DURATION AIJD SCOPE OF SERVICES PROVIDED MEDICALLY IJEEDY GROUP(S): The following ambulatory services are provided. 11The §ervices provided to the medically needy are the sane as those provides to the categorically needy". *Description provided on attachment. TN N'o. 'Ei']- \ 2 6 1988 JAN. l 1987 Supersedes Approval Date MAY Effective Date~--~--- TN No. ~£-8 HCFA ID: 0140P/0102A OH\C\~l ATTACHMENT 3.1-B Page 1 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): ------ 1. Inpatient hospital services other than those provided in an institution for mental diseases. X Provided __ No limitations X With limitations" 2:a. Outpatient hospital services. X Provided __ No limitations X With limitations" 2.b. Rural health clinic services. and other ambulatory services furnished by a rural health clinic. X Provided __ No limitations X · With limitations" 2.c. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with section 4231 of the State Medicaid Manual (HCF A-Pub. 45-4). X . Provided __ No limitations X With limitations* 2.d. Ambulatory services offered by a health center receiving funds tinder section 329, 330, or 340 of the Public Health Services Act to a pregnant woman or individual under 18 years of age. _X_ _ Provided: __ No limitations X With limitations" 3. Other laboratory and x-ray services. X Provided __ No limitations X With limitations" *Description provided on attac~. TNNo. ~ -tm ., 7 . · O'f 05 ~ 1JQ 1 3 iti0'3 Effective Da~ ----- ( \..•~... Attachment 3.1.B Pagc2 ST A TE eLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State Agency Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUPS 4.a. Nursing facility services (other than services in an institution fOI' mental diseases) for individuals 21 years of age or order, _Provided _____N"o Limitations __ With limltatlons" X Not Provided 4 .Ii. Early and period ic screening, diagnostic and treatment services for individuals under 21 years of age, and treatment of cond ltlons found. · ..2L Provided .XNo Limitations _Wit11 llmltatlons" 4.c. Family planning services and supplies for indlviduals of child-bearing age . .K:. Provided _No Limitations X With-limitations:!< 4.d. 1) Face-to-Face Tobacco Cessation Counseling Services provided: X (i) By or under supervlslon of a physician; X.(ii) By any other health care professional who is legally autltorlzed to furnish such services: under State law and who is authorized to provide Medicaid coverable. services other than tobacco cessation services; or (Hi) A1ty ether health care professional legally authorized to provldetobacco cessation services under State law <{11 2).Face~to-:l<'.l\cc Tobacco Cessntton Couuscllng Services for Pregnant Women Provided: X No Jlmltatlons With llinitations" *Any beneflrpackage' that consists of less than four (4) counseling sessions per quit attempt, with a minimum of two (2) quit attempts per 12 month period should be explained below. Please describe any I imitations! 5.a. Phystclans' services whether furnished in the office, the patient's home, a hospital, a nursing facility or elsewhere. X Provided __ No Limitations .X With llmitationa" · 5.b, Medical-and sutglcal services furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act). X Provided _No Limitations .X. With limitations* 6. Medical care and any other type of remedial carerecogntzed under Statelaw, furnished by licensed practitioners within the scope of their practice as defined by State law, a. Podlatrists' services X Provided _NQ Limftations .X With [imitations" *Descrlplion provided on nttachmenr, 2014 OCT o 1 2013 TN N9. 13~004 Approval Date JAN 2 s Effective Date Supersedes TNNo. 03~001A Attachment 3.1-B Page 3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO I . AMOUNT, DURA TTON, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY b. Optometrists' services ~Provided D No limitation IZl With limitations" D Not Provided c. Chiropractors' services [8] Provided D No limitation IZJ With limitations" D Not Provided d. Other practitioners' services ~ Provided D No limitation IZJ With limitations" D Not Provided 7. Home Health Services a. Intermittent or part-time nursing services provided by a home health agency or by a .registered nurse when no home health agency exists in the area. D Provided D No limitation D With limitations" ~Not Provided under the PRHIA Health Reform Plan b. Home health aide services provided by a home health agency. 0 Provided D No limitation D With limitations" [gj Not Provided under the PRHIA Health Reform Plan c. Medical supplies, equipment; and appliances suitable for use in the home. D Provided D No limitation 0 With limitations* 12.Sl Not Provided under the PRHIA Health Reform Plan * Description provided on Attachment. Transmittal No.: 14-008 Effective Date: July 1, 2014 Supersedes TN No.: 03-001-A Approval Date: \&\\Y\\\L\ \ \' . { \. ATTACHMENT 3.1-B Page 3a State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): _ d. Physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility. ~--·Provided __ No limitations With limitations" X Not Provided under Health Reform Plan by PRHIA 8. Private duty nursing services. ___ Provided -~No limitations __ With limitations* X Not Provided under Health Reform Plan by PRHIA ATTACHMENT 3.1-B Page4 State/Territory: Puerto Rico _ AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): ------~ 9. Clinic services. -~X""---~Provided __ No limitations X With limitations" 10. Dental services. -~X~_Provide:d __ No limitations _X_With limitations* 11. Physical therapy and related services. a. Physical therapy _ _,X=-~Provided __ No limitations X With limitations" b. Occupational therapy -~X=-=-_Provided X No limitations __ With limitations" c. Services for individuals with speech, hearing, and language disorders (provided by or under the supervision of a speech pathologist or audiologist) ---'X=-_P.rovided X No limitations __ With limitations* *Description pro'"ded~nt. TN No. ()~ - 129 MAR O 5 AUG 1 3 2003 Effective Date - ATTACHMENT 3.1-B r· Page 5 STATE/TEHRITORY: PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY 12. Prescribed drugs, dentures, and prosthetic devices: and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist. a. Prescribed drugs [ZJ Provided D No limitation C8J With limitations* D Not Provided b. Dentures D Provided D No limitation D With limitations* (ZJ Not Provided c. Prosthetic devices (ZJ Provided D No limitation IZJ With limitations* D Not Provided d. Eyeglasses [ZJ Provided D No limitation IZI With limitatlons" 0 Not Provided (Provided based on EPSDT Guide) 13. Other diagnostic, screening, preventive, and rehabilitative services, i,e., other than those provided elsewhere in the plan. a. Diagnostic services IZI Provided 0 No limitation IZI With limitations* D Not Provided "Description provided on attachment. II -----~- --- -···-~------i, ~ 02/16/2016 TN No.: _ Approval Date: Effective Date: January 1. ~016 Supersedes: 03-001-A I 11 ~ ATTACHMENT 3.1-B Off\C\~l Page 6 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): ------ b. Screening services _ _,X'-"-~Provided __ No limitations X With limitations" c. Preventive services _ _,X'-"-_Provided __ No limitations X With limitations* d. Rehabilitative services -~X~_Provided __ No limitations X With limitations* 14. Services for individuals age 65 or older in institutions for mental diseases. a. . Inpatient hospital services X Provided X No limitations __ With limitations" (Based on medical necessity Law 408) ___ Not Provided b. Skilled nursing facility services ~ Provided __ No limitations __ With limitations* X Not Provided c. Intermediate care facility services ____ Provided __ No limitations __ With limitations" X Not Provided *Description provided on attachment. TN No. ():J -'fl&('ll MAR 0 5 28M AUG 1 3 2003 :~~~d~7 _, 7 Approval Date · Effective Date ~ ATIACHMENT 3.l~B Page 7 STATE/HRRITORY: PUERTO RICO AMOUNT1 DURATION, ANO SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY 15. ~. Intermediate care facility services (other than such services In an institutfon for mental diseases) for persons determined, In accordance with section 1902(a)(31)(A) of the Act, to be in need of such care. D Provided 0 No limitation D With limitations* [g] Not Provided b. Including such services In a public Institution (or distinct part thereof) for the mentally retarded or persons with related condttlons, 0 Provided 0 No limitation D With limitations* !%] Not Provided 16. Inpatient psvchlatrlc facility services for individuals under 22 years of age. ~ Provided ~· No limitation D With llmltattons" 0 Not Provided (Based on Medical Necessity under Law 408) 17. Nurse-midwife services D Provided 0 No !imitation D With ltmltarlons" ~ Not Provided· 18. Hospice care (in accordance wfth section 1905(0) of the Act). D Provided 0 No limitation ~ Not Provided fZI Provided 0 With limitations* In accordance wlth section 2302 of the: Affordable Care Act "Description provided on attachment. ------ TN No.: . 14~0(!_~------ApprovalDate: JUL 1 02014 Effective Date: Apr!l 1, 2014 Supersedes: 03-001-A ATTACHMENT 3.1-B Page 8 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): ------ 19. Case management services and Tuberculosis related services a. Case management services as defined in, and to the group specified in, Supplement 1 to ATTACHMENT 3.1-A (in accordance with section 1905(a)(19) or section 191 S(g) of the Act). _X=-=-_.Provided X With limitations" __ Not Provided b. Special tuberculosis (TB) related services under section 1902(z)(2)(F) of the Act. X Provided X With limitations" __ Not Provided 20. Extended services for pregnant women a. Pregnancy-related and postpartum services for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60111 day fall. X Provided X Additional coverage ++ b. Services for any medical conditions that may complicate pregnancy. X Provided ~~X~_.Additional coverage ++ + + Attached is a description of increases in covered services beyond limitations for all groups described in this attachment and/or any additional services provided to pregnant women only. * Description provided on attachment. Post partum and pregnancy-related services after the pregnancy ends are covered beyond the 601h day if •·· medically needed. Services for any other medical conditions that may complicate pregnancy are provided without limitations. TN No. f) 3>-- CTD//t MAR 0 5 7:004 Effective DateAUG 1 3 2D03 Offl&\~l ATTACHMENT 3.1-B Page 8a State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S). 21. Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period by a qualified provider(in accordance with sectionl Szf] of the Act) ___ Provided __ No limitations __ With limitations* X Not Provided 22. Respiratory care services (in accordance with section 1902(e)(9)(A) through (C) of the Act). ___ Provided __ No I imitations __ With limitations* X Not Provided 23. Pediatric or family nurse practitioners' services. X Provided __ No limitations With limitations* (According to our Health Plan coverage and state licensing laws - general nurse practitioners) *Description provided on attachment. TN No. . () ,,, ®1'11 MAR Effective D~~G 1 3 2003 ~~~~desg:C.,; I Approval Date O 5 1!!01 ATTACHMENT 3.1-B Off Page 9 State/Territory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S) 24. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary. a. Transportation. -~X~~Provided __ No limitations ___L With limitations* b. Services of Christian Science nurses. ___ Provided __ No limitations __ With limitations" X Not Provided c. Care and services provided in Christian Science sanitoria. ___ Provided __ No limitations __ With limitations* X Not Provided d. Nursing facility services for patients under 21 years of age. ____ Provided __ No limitations __ With limitations* X Not Provided e. Emergency hospital services. -~X~_Provided X No limitations __ With limitations" f. Personal care services in recipient's home, prescribed in accordance with a plan of treatment and provided by a qualified person under supervision of a registered nurse. ___ Provided -·--· __ No limitations __ With limitations* X Not Provided· *Description provided on attachment. MAR O 5 2004 AUG 1 3 2003 Approval Date Effective Date _ ATTACHMENT 3.1-B Page 10 State/Tenitory: Puerto Rico AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): 25. Home and Community Care for Functionally Disabled Elderly Individuals, as defined, described and limited in Supplement 2 to Attachment 3.1-A, and Appendices A-G to Supplement 2 to Attachment 3.1-A. __ No limitations __ With limitations* X Not Provided *Description provided on attachment. AUG 1 3 2003 Superse 7s CJf '! ..-, Approval Date Effective Date ----- TN No. =t ~-' '1-1' Attachment 3.1-B Page 10 a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURI1Y ACT State Agency Puerto Rico MEDICAID PROGRAM: REQUIREMENTS RELATING TO COVERED OUTPATIENT DRUGS FOR THE MEDICALLY NEEDY 12.a. Prescribed Drugs: Description of Service Limitation Citation(s) Provision( s) 1935(d)(l) Effective January I, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B. 1927(d)(2) and 1935(d)(2) The Medicaid-agency provides coverage for the fol1owing excluded or otherwise restricted drugs or classes of drugs, or their medical uses to all Medicaid recipients, including full benefit dual eligible beneficiaries under the Medicare Prescription Drug Benefit-Part D. · [BJ The following excluded drugs are covered: ("All" drugs categories covered under the drug class) D (t'Some" drugs categories covered under the drug class D -List the covered common drug categories not individual drug products directly under the drug class) (t'None" of the drugs under this drug class are covered) D 00 (a) agents when used for anorexia, weight loss, weight gain are excluded as a general rule. Puerto Rico provides coverage of medicallv-necessary mental health drugs when used in the treatment of anorexia according to the medical psychiatric practice accepted norms as required for the diagnosis, prevention, and treatment of the mental health disease. 0 (b) agents when used to promote fertility D (c) agents when used for cosmetic purposes or hair growth D (d) agents when used for the symptomatic relief of cough and colds 1N No. 13-002 Approval Date!JUN 2 0 2'113 Effective Date January l, 2013 Supersedes TNNo. New Attachment 3.1-B . Page 10 b STATE PLAN UNDER TITLE XIX OF TIIE SOCIAL SECURITY ACT State Agency Puerto Rico MEDICAID PROGRAM: REQUIREMENTS RELATING TO COVERED OUTPATIENT DRUGS FOR THE MEDICALLY NEEDY 12.a. Prescribed Drugs: Description of Service Limitation Citation(s) Provision(s) !El (e) prescription vitamins and mineral .products are excluded as a general rule, except prenatal vitamins and fluoride. Puerto Rico also covers some vitamins and mineral products when there are prescribed, medically necessary, and used in the treatment of cancer, renal disease, or HIV/AIDS. !El (f) nonprescription drugs or over-the-counter (OTC) drugs are excJuded as a 2eneral rule. Puerto Rico covers some OTC drugs (Non Sedating Antihistamines, Antihistamine, Respiratory Agent, Antiplatelet, and Topical Antimycotic products) when they are prescribed and medically necessary according to the medical practice accepted norms as required for the diagnosis, prevention, and treatment of the disease .. 0 (g) covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee (see specific drug categories below) I&! (h) barbiturates for non-dually eligible. Puerto Rico does not provide coverage for dual eligible individuals with Medicare Part D, because of effective Januarv l, 2013, Part D covers these drugs when used in the treatment of epilepsy, cancer, or a chronic mental health disorder; except when these drugs are prescribed for a condition other than the three covered by Part D and during Part D donut hole period if it is medically necessary. IB.l (i) benzodiazepines for non-dually eligible. Puerto Rico does not provide coverage for dual eligible individuals with Medicare Part D, because of effective January 1, 2013, Part D covers all indications for these drugs; except for dually eligible without Part D and during Part D donut bole period if it is medically necessary. ~ G) smoking cessation drugs are excluded except for individuals under aee 21 and for pregnant women when medically necessary and prescribed by a physician. In these cases the plan covers prescription and non-prescription aids as indicated by a physician and without cost-sharine;. TN No. 13-002 Approval Date rJJN 2 0 2013 Effective Date January l, 2013 Supersedes TNNo. New Description for Attachment 3,1-B Page 1 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY Description of Limitations General Limitations The following General Limitations and Exclusions apply to all services not just inpatient or outpatient services: a. Services rendered while the beneficiary is not covered. b. Services which result from illnesses or injuries not covered. c. Services resulting from automobile accidents which are coveted by the Automobile Accident Compensation Fund (ACAA). d. Workman's compensation accidents covered by the "Fondo del Seguro del Estado". e. Services covered by any other insurer or party that has the primary responsibility (other party liability). f. Special nurses services for the convenience of the patient when it is not medically necessary. g. Hospitalization for services which can be rendered in an ambulatory setting. h. Admission of patients to hospitals for diagnostic purposes only. L Expenses for services and/or materials for the comfort of the patient, such as telephone, television, admission kit, etc. j. .Services rendered by second generation family members of patient (parents, offspring, siblings, grandparents, grandchildren, spouse, eto.). k. Organ and tissue transplants, except as provided in Attachment 3 .1-E, I. Laboratories for which processing is not available in Puerto Rico and that have to be sent outside of Puerto Rico for processing, m, Treatments with the purpose of controlling weight (obesity. or weight increase) solely for esthetic purposes. n. Sports Medicine, musical therapy, and natural medicine. o. Tuboplasties, vasovasectomies and any other procedures or services for the purpose of returning the ability to procreate, are excluded: Transmittal No.: 14-008 Effective Date: July 1. 2014 Supersedes TN No.: 03-001-A Approval Date: _\_~_\-+,~~'(\~~+-~,__\..,__, _ Description for Attachment 3.1-B Page2 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THEMEDICALLYNEEJ;)Y Description. of Limitations p, Cosmetic surgery and treatment, solely to correct defects in the physical appearance, excluding also hospitalization, medical-surgical services and complications associated with this procedure, regardless of their medical justification, q. Services, diagnostics tests and/or treatments ordered and/or provided by naturopaths, naturists, and iridologists, r, Mammoplasty or plastic reconstruction of the breast solely for cosmetic purposes. s. Ambulatory setting use of fetal monitor. t. Services, treatment or hospitalizations which arise from an induced abortion (not therapeutic). The following are considered induced abortions: DESCRIPTION 59840 Induced abortion, by dilation and curettage 59841 Induced abortion, by dilation and expulsion 59850 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines); 59851 Induced abortion; by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines); with dilation and curettage and/or evacuation. 59852 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines); with hysterectomy (failed intra• amniotic injection). Transmittal No.: 14-008 Effective Date: July 1. 2014 Supersedes TN No.: 03-001-A Approval Date: '~,\v\\ \\..\ ' \ \ Description for Attachment 3.1-B STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Puerto Rico Page 3 AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): Description of Limitations 59855 Induced abortion, by one or more vaginal suppositories (e.g., prostaglandin) with or without cervical dilation (e.g., Iaminaria), including hospital admission and visits, delivery of fetus and secundines 59856 Induced abortion, by one or more vaginal suppositories (e.g., prostaglandin) with dilation and curettage and/or evacuation. 59857 Induced abortion, by one or more vaginal suppositories (e.g., prostaglandin) with hysterectomy (omitted medical expulsion). u. The Revetron drug. v. Services for epidural anesthesia w. Sornnography studies. x. Services which are not reasonable nor required according to the accepted standards of medical practice or services provided in excess of those normally required for the prevention, diagnosis, and treatment of a disease, injury or dysfunction of the organic system or pregnancy condition. y. Hemodialysis and/or peritoneal dialysis services are excluded from the Basic Coverage; but included in the Special Coverage. z. New and/or experimental procedures which have not been approved by the PRHIA for their inclusion as benefits in the basic and special coverage of the program. aa. Custodial, rest or convalescence services, in cases where the acute medical condition requiring in-patient care is under control or in irreversible terminal cases. bb. Expenses incurred in payments made by beneficiaries to participating providers that according to the terms of the program, the beneficiary was not supposed to pay. cc. Services ordered and/or rendered by non-participating providers, except in cases of emergencies/immediate need or previously authorized by the HCOs or MCO. dd. Neurological and cardiovascular surgery and related services are excluded from the Basic Coverage, but included in the Special Coverage. TN No. tJ'() JQI . MAR 0 5 2004 1)3"' f AUG 1 3 2003 Supersedes ' lpproval Date Effective Date ~1 ~l ------TN N0. :.n•tJ .. ,~n;,sg ~. '\~ ~\.. / ;s{W" . Description for Attachment 3.1-B Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/TERRITORY: PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY Description of Limitations ee. Services received outside of the territorial limits of the Commonwealth of Puerto Rico, except for emergency services received in the United States. ff. Expenses incurred for the treatment of conditions, resulting from procedures or benefits not covered under this Program. Maintenance prescriptions and required laboratories for the continuity of a stable health condition, as well as any emergencies which could result after the referred procedures, are covered. gg. Travel expenses, even when ordered by the primary care physician or participating provider are excluded. hh, Eyeglasses, lenses, and hearing aids are excluded, except for beneficiarles under age 21 when it is medically necessary and approved through a prior authorization process. ii. Acupuncture services are excluded. ll- Rent or purchase of wheelchair or any other vehicle (motor and/or electric) or expenses for the repair or alteration of these vehicles. kk, Procedures with the purpose of changing the sex of the beneficiary. II. Treatment services for infertility and/or related to conception by artificial means. 1. Inpatient hospital services other than those provided in an institution for mental diseases Inpatient services are provided within coverage under Health Reform Plan with limitations: Limitations on inpatient services: o Bed in Semiprivate Room: Coverage will be available twenty four (24) hours per day, every day of the year. g Isolation Room; For medical reasons. &> Specialized Diagnostic I Treatment: Electrocardiograms, electroencephalograms, arterial gases, and other specialized diagnostic and/or treatment testing that are available in the hospital facilities and which me required to be performed while the patient is hospitalized. TN No.: _ Approval Date: 02/16/2016 Effective Date; January 1._2016 Supersedes: 03-Q91-A Description for Attachment 3.1-B STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Puerto Rico Page5 AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): Description of Limitations Limitations to inpatient services: • Short Tenn Rehabilitation Services: To hospitalized patients, including physical, occupational, and speech therapy. • Blood: Blood, plasma and their derivatives without limitations, to include irradiated and autologous blood; Monoclonal Factor IX per authorization of an certified hematologist; Antihemophyllic Factor with intermediate purity concentration (Factor VIII); Antihemophyllic Monoclonal Type Factor per authorization of a certified hematologist and Protrombin Activated Complex (Autoflex and Feiba) per authorization of a certified hematologist. 2a. Outpatient services are covered by the Reforma Health Plan. 2b. Rural health clinic and ambulatory services provided are those categorized benefits covered according to our Reforma Health Plan. 2c. Federally Qualified Health Centers services and other ambulatory services are those benefits covered according to our Reforma Health Plan. TN No. 0 ~--61) / " AR o 5 2004 Superse STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATp I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY 3. Other laboratory and X-ray services. Diagnostic blood tests and X-rays are covered, but the following special procedures and diagnostic tests are provided subject to benefits included under the plan's special coverage and medical necessity criteria: a. Computerized tomography. b. Magnetic Resonance Tests Imaging c. Cardiac catheterization d. Holter Tests e. Doppler Tests f. Stress Tests g. Lithotripsy h. Electromyography 1. Single Photon Emission Computerized - Tomography Test (SPECT) J. Ocular Plesthymography (OPG) k. Impedance Plesthymography 1. Other invasive and non-invasive cardiovascular, cerebrovascular, and neurosurgical procedures m. Nuclear Medicine tests n. Endoscopies for diagnostic purposes o. Genetic Studies. 4.c. Family Planning Services: The coverage benefits of the Puerto Rico Medicaid and CHIP Programs provide the following Family Planning Services: (i) education and counseling, (ii) pregnancy testing, (iii) infertility assessment, (iv) sterilization services in accordance with 42 CFR 441.200 subpart F, (v) laboratory services, (vi) at least one of every class and category of FDA (Food and Drug Administration) approved contraceptive medication, (vii) cost and insertion/removal of non-oral products, such as long acting reversible contraceptives (LARC), and (viii) other FDA approved contraceptive medications or methods when it is medically necessary and approved through a prior authorization or exception process. 5.a. Physician services in the patient's home are provided based on medical .necessity. Transmittal No.: 15-001 Effective Date: April l, 2015 SEP o 9 2015 Supersedes TN No.: 03-001-A Approval Date: {--• Description for Attaclunent 3.1-B ,_ Page 7 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY 5b. Medical and surgical services provided by dentist are limited to the coverage services description on item (10). 6a. Podiatrist services are provided as remedial and incidental care rendered for attending special conditions under the Health Reform Plan's special coverage. 6b. Optometrist services are limited to vision evaluations and exams. 6c. Chiropractic services ns determined medically necessary. Initial 15 sessions available without prior authorization. Additional 15 sessions require prior authorization. The treatment limit is combined with the limit for physical therapy. An individual may receive a total of 30 physical therapy and/or chiropractic sessions combined. Additional session beyond 30 is allowed with medical necessity and requires a prior authorization process. 6d. Most types of practitioners· are included, except for: alternative and sport medicine practitioners, iridologist, naturopaths, and cosmetic plastic surgeons. 7. Home Health Services No FFP is claimed for Home Health Services. Transmittal No.: 14-008 EffectiveDat e: July l. 2014 Supersedes TN No.: 03-001-A Approval Date: \ ~\l \r\\\'-\ I Description for Attachment 3.1-B Page8 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/ TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICALAND REMEDIALCARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY 11. Clinic services are provided accordingto and within to the State Plan coverage and complaint with 42 CFR 440.90, lncludlng preventive, diagnostic, therapeutic, rehabllitatlve, Qr palliative services that are furnished by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. The. term includes the following services furnished to outpatients: (a) services furnished at the clinic by or under the dlrectlon of a physician or dentist and (b) services furnished outside the clinic, by clinic personnel under the direction of a physician, to an eligible individual who does not reside in a permanent dwelflng or does not have a fixed home or mailing address. These clinics: include Department of Health Clinics,. Preven Cffnics, Urgent Care Clinics, and Physician operated clinics, · · 12. Dental Services a. Dental Services for Chi!cjren Under 2'.!. Years of Age • AH preventive and corrective dental services .are covered for children under age 21 (0-20) as indicated under Early .and Periodic Screenlng, Diagnostic, and Treatment {EPSDT) benefit requirement. • Orthodontic services to EPSDT elfgible children as medically necessary to prevent and restore oral structures to health and function are covered. Orthodontic services for cosmetic purposes are not covered. • Pediatric Pulp Therapy .(Pulpotomy) for chlldren under age twenty-one (21) and stainless steel crowns for use in primary teeth following a Pediatric Pulpotomy. · • Anesthesia services (subject to prior authorlzatlonl for a child with physical or mental handicaps in compliance with federal and local laws. Those special conditions includes, but not limited to, the followings: (a) autism, (b} severe retardation, (c} severe neurologic impairment, (d) significant attention deficit disorders with hyperactivity, (e) significant or severe mental disorders, (f} disable or unable to follow commands, and (g) any other condition that at the dentist professional judgment, impaired the required patient cooperation and feaslbiflty to adequatelvperform the dental procedure. • All limitations may be exceeded based on medfca! necessity and approved through a prior authorfzatlon or exception process. Transmittal No.: PR-16-0003 Effective Date: July 1, 2016 supersedes TN No.: 15-0001 Approval Date: __ J_U_L_Y_o_s_, _2_01_6 _ Description for Attachment 3.1-A Page 8a STATE .PLAN UNQER TITLE XIX OF THE SOCIAL SECURITY ACT STATE/ TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE-OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY 10. Dental Services · b. Dental Services for Members Age 21 and Over When It is Medlcally Necessary: • Preventive dental services • Restorative dental services • One (1) comprehensive oral examlnatlon per year • One (1) Perlodlc oral examination every six (6) months • One (1) defined probtem-Hmlted oral exam • One (1) full series of fntra-oral radlographles, including bltewlngs, every three (3) years • One (1) initial perfapical lntra-oral radiography • Up toflve (5) additional perteplcal/lntra-oral radiographies per year • ·One (1) slngle fllm-bltewlng radiography per year • One (1) two-film bitewlngs radlographv per year • One {1} panoramic radiography every three. (3) years • One (1) cleanse every. six (6) months • One (1) Prophylaxis, every six (6) months • Amalgam restoration • Resin restorations • Root canal • Palllatlve treatment • Oral surgery • Anesthesia services {subject to prior authorization) for beneficiaries with physical or mental handicaps in compliance with local law • All llmltattons may be exceeded based on medical necessity and approved through a prior authorization or exceptlon process. Transmittal No.: PR-16-0003 Effective Date: JUiy 1. 2016 Supersedes TN No.: NEW Approval Date: _J_U_L_Y_o_s_, _20_1_6 _ Description for Attachment 3 .1-B (. Page9 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE-/ TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY Description of Limitation 11.a. Physical therapy and or chiropractor services as determined medically necessary. a. Initial 15 sessions available without prior authorization. b. Additional 15 sessions require prior authorization. c. The treatment limit is combined with the limit for chiropractic care. d. An individual may receive a total of 30 physical therapy and/or chiropractic sessions combined. e. Additional session beyond 30 is allowed with medical necessity and requires a prior authorization process. 12.a. Prescribed drugs a. The PRHIA maintains a drug Formulary as the official formulary of drugs provided lt.-,.: ... by the Health Reform Plan coverage, which contains most of the vast majority of therapeutic alterative categories available. b. A preferred drug list (PDL) is also maintained as a cost-effective utilization tool in rendering prescription benefits under the Health Reform Plan. c. The MCOs, MBHOs, and Direct Providers, that are contracted, agree to conduct the pharmacy billing and claims through the PRHIA's contracted Pharmacy Benefits Manager (PBM). d. · Under exceptional circumstances, a drug not included in the Formulary could be covered only through exceptional circumstances and procedure set forth below. Transmittal No.: 15-001 Effective Date: April 1. 2015 SEP o 9 2015 • Supersedes TN No.: 14-008 Approval Date: Description for Attachment 3.1-B Page 9a STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY Description of Limitation Limitations and Conditions of the Prescription Services a. Contraceptives drugs are covered under the Health Reform Plan for the treatment of menstrual dysfunction and for birth control purposes, as follows: (i) At least one of every class and category of FDA (Food and Drug Administration) approved contraceptive medication, (ii) At least one of every class and category of FDA approved contraceptive 'method, and (iii) Other FDA approved contraceptive medications or methods when it is medically necessary and approved through a prior authorization or exception process. b. Drugs required for the ambulatory or hospitalized treatment of diagnosed beneficiaries with AIDS or with an HIV positive factor are covered under the special coverage to include only antiretrovirals but excluding Protease inhibitors. The Protease inhibitors are not covered benefits financed under the Health Reform Plan, they are provided to Medicaid beneficiaries through coordination with the Regional Immunological Clinics of the Commonwealth Health Department's PASET Division. c. Immunosuppressant drugs for all transplant patients are covered only to the extent of maintenance treatment post-surgery to ensure the continuity of health stability of the beneficiary, as well as emergencies that may result after surgery (as transplants are not covered). d. New drugs for future inclusion are evaluated through an active process for revising on a continuous basis and evaluate the future inclusion of new medicines or the removal of medicines from the formulary. Considering the dynamic nature of this process, the PRHIA requires the inclusion or exclusion of medicines as changes and advances affect the standard practice for the treatment of conditions or developments of standard practices for the treatment of a condition or particular treatments. Transmittal No.: 15-001 Effective Date: Aprill, 2015 SEP o 9 2015 Supersedes TN No.: 14-008 Approval Date: Description for Attachment 3.1-B STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT State/Territory: Puerto Rico Page 10 AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED MEDICALLY NEEDY GROUP(S): e. .No MCO,HCO, MBHO or providers can establish a different formulary from the one included in this addendum nor limit in any way the drugs and medications included in the formulary, f. In the event a beneficiary needs a drug or medicine that is uot included in the formulary, the MCO, MBHO and providers will follow the usual pre-authorization procedure, to obtain drugs not included in the formulary. The provider shall have to obtain the MCOs prior approval considering and documenting the particular merits of each case, which could include among others the following criteria: 1. A contraindication of drug that appears in the formulary. 2. Adverse reaction history to the drug that appears in the formulary, 3. Therapeutic failure to all available alternatives in the formulary. 4. Non-existence of alternative therapy in the formulary. g. For acute conditions, the amount of medication to be dispensed shall be limited to the needed therapy, but never for more than fifteen (15) days. When medically necessary, additional prescriptions are covered. h. For chronic conditions (maintenance), the amount of the medication to be dispensed will be limited to a maximum of thirty (30) days. By prescribing physician recommendation, each prescription may be repeated up to six (6) times. When medically necessary, additional prescriptions are covered. i. The indications on prescriptions issued for treatment of children with Special Health Care Needs will indicate dearly the (30) day coverage therapy and that it can be repeated up to six ( 6) times. When medically necessary additional prescriptions will be covered. j. The use ofbioequivalent medications and drugs approved by the FDA and local regulations is authorized, unless contraindicated for the beneficiary by the physician or dentist who prescribed the medication. k, The absence of bioequivalent medications in stock does not exonerate the Pharmacist from dispensing the medication nor does it entail the payment of additional surcharges by beneficiaries. Brand name drugs will be dispensed if the bioequivalent is not available at the pharmacy. I. All prescriptions shall be filled and dispensed at a participating pharmacy properly licensed under the laws of Puerto Rico freely chosen by the beneficiary. m. All prescriptions shall be dispensed contemporaneously with the date and hour that the beneficiary receives the prescription and requests that it be dispensed. TNNo. 03-'{7f)J A · HARO 5 200"4 t: ti D AUG 1 3 2003 Supersed~so:lJ,.' .-2._ Approval Date Ef1ec 1ve ate ~- TN No. _Q_-=t- """"'..,/ Description for Attachment 3.1-B Page 11 STATE PLAN UNDER TITLE XIX OF IHE SOCIALS ECURITY ACT STATE/TERRITORY: PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY 12c. Prosthetic devices "Those including all of the extremities of the body,· the ocular therapeutic prosthesis and the segrnentarv instrumentation system trays for scoliosis surgery and fusion. 12d. Eyeglasses Eyeglasses or lenses are covered for Medicaid beneficiaries under age 21 when those are medically necessary. Eyeglasses or lenses benefit consist of a single or multi-focal lenses and one standard frame every 24 months. All type of lenses needs to be preauthorized, except for lntraocular lenses. The repair or replacement of eyeglasses within the 24-rnonths term is covered when it is medically necessary and approved through a prior authorization process. 13a. Diagnostic Services General clinical laboratories, x-ravs, radiotherapy, pathology, pulmonary function and electroencephalograrns if necessary for treatment and convalescent care are not subject to pre-authorizations by the PCP or HCO. For the special coverage diagnostic services described in item 3 above they are subject to necessity criteria and pre-authorization. 13b. Screening Services _, Gynecological and Prostate Cancer screening according to accepted medical practice, including Papanicolaou test, mammographies, and P.S.A. as may be medically necessary and according to the age of the beneficiary. Accordingly to Puerto Rico's Health Policies the age of forty (40) years have been established as the initial date to commence cancer screening by mammography. Sigmoidoscopy for adults ages 50 and over with risk of colon cancer according to accepted medical practice. TN No.: _ Approval Date: 0211612016 Effective Date: January 1. 2016 Supersedes: 03-001-A Description for Attachment 3. 1 ~ B Page 12 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY Description of Limitation 13c. Preventive services A comprehensive annual health evaluation for each beneficiary, to be performed by a qualified health professional including eye tests, hearing test, nutritional screening and evaluation, laboratories and all other exams and diagnostic tests, and immunizations commensurate with age, gender, and physical condition of the beneficiary. This annual evaluation complements the services for children and adolescents to be provided accordingly with the periodicity schedules published by the American Academy of Pediatrics and EPSDT under Title XIX of the Medicaid program. Follow-up visits will be provided to all beneficiaries based on medical necessity criteria established by the State. All immunizations will be provided for children to age 21 and those necessary according to age, gender, and health condition of the beneficiary, including but not limited to influenza and pneumonia vaccines fol' beneficiaries over 65 years and vaccines for children and adults with high risk conditions such as pulmonary, renal, diabetes, and heart disease, among others. The Puerto Rico Department of Health provides vaccines to children ages 0-18 through the Children's Immunization Program. The coverage benefits of the Puerto Rico Medicaid Program also include immunizations for Medicaid beneficiaries' ages 19-20. Each managed care organization (MCO), contracted by the State, will contract with immunization providers, duly certified by the Puerto Rico Department of Health, to provide the immunization services. Immunizations will be administered without any charge or deductibles. Counseling in physical health, oral health, and nutrition will be provided in accordance with the preventive service benefit to address the individual needs of the beneficiaries based on their health conditions. Transmittal No.: 15-002 Effective Date: April 1, 2015 Supersedes TN No.: 03-001-A Approval Date: _Si_ep_t_em_b_er_l_l._l_O_I S _ Description for Attachment 3. I ~B Page 13 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED TO THE MEDICALLY NEEDY Description of Limitation l3d. Rehabilitative services The rehabilitative services provided are ambulatory. Except for physical therapy, all rehabilitative services such as: respiratory, occupational, and speech therapies services are unlimited. Physical therapy and/or chiropractic services (chiropractic manipulation sessions) as determined medically necessary. Initial 15 sessions available without prior authorization, Additional 15 sessions require prior authorization. The treatment limit is combined for chiropractic care and physical therapy. An individual may receive a total of 30 physical therapy and/or chiropractic sessions combined. Additional session beyond 30 is allowed with medical necessity and requires a prior authorization process. 19. Ambulatory treatment, hospitalization and other TB related services and case management are covered under the Special Coverage. 20. The extended services for pregnant women besides covering all pre-natal, delivery and post• partum care services, include all medical and obstetrical nursing services during the delivery, be it natural childbirth, cesarean section, 01· any other complication; hospitalization beyond minimum stay terms in case of maternity, high risk or secondary conditions to the pregnancy by medical recommendation. The minimum stay term for hospitalization for both mother and newborn will not be limited to less than 48 hours for normal vaginal delivery without complications and in the case of childbirth following cesarean section, the stay may not be limited to less than 96 hours for both mother and child. 24.a. Transportatlon Limited to ambulance services in emergency cases, ground, maritime, and aerial ambulance services are covered within the territorial limits of Puerto Rico. No pre-authorization or .pre~ certification will be required in order to access these services. In general, the service shall be accessed either by beneficiary calling 911 or calling the local ambulance provider contracted and as instructed by the HCO and the MCO in the area. For non emergency transportation the Commonwealth follows the methods described in attachment 3.1-D of this plan. Transmittal No.: 14~008 Effective Date: July 1. 2014 Supersedes TN No.: 03~001-A Approval Date: \s\\ 'f\\\L \ I ' \' \ · ..:.· .· . . . ,.;,:!· .. •.. . .· ..\-~ ~. . .. . ,. ~· ,. . . . ':..•.I.' . ' :-.'\~··· ~--; ,:.· .' :-·· ...... ( ..,.;:· .. · Attachment 3.l•C , .. : . . STA'J=E PLAN UNDER." "TITLE XIX OF THE. .socrer. SECURITY. AC'X - -, ... " ~ ...... ·. State ··comnonwealth of Puerto Rico ' . . •' ·- .. . :. . I l .; . ~ · ..: .... .: The_ Department of Health is the state licensing agency for Hospitals; Nursjng Homes and intcnnediate care.health.facili~1es. ·The Office of : Liccnsure and Certification 0£ Health Facil;ities detenninesJ Lssue the standards and supervises the efficient opperation of· health facilities in Puerto .. Rico; except· for· free standing··laboratories . t .. -,t ··that ore licensed by the Institute of Laboratories acccrddng to .• f standards 'p romuIgat.ed by ·the· secrenary 'of Health • I . A' register of licensed hospitals and nursing homes ·in Puerto Rico · is published·annualiy by said Office •. A listing of licensed labor~torics is published by the. Institute. . · ·The Office of Licensure and Certification of Health Facilities has a· staff of qualified in~pec.tors and consultants that visit periodically the licensed facilities to assure continuing eligibility. ·:...~· f .. • 'The-·Institute ·has its ccn staff thnt .visits free _?tanding laboratories 't ". . regularly. .'Standards and records· relative. to licensing and certification. of hea Lth . facilities and··free standing Iabcracordes are available to the Medical ....• Assistance Program.· . t;f . .. ·. .· ...... ' . . ~- . ' . t·' ... , . -. ··.· ·... ·· :: .· .. ::.·· .. , .. • ... . · :...... :~· • . ·.r' .·. ~ .. ... ~ . . · ...... : :...... Attaclunent .3.1'.".'P STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF __ c_o_mm_o_n_w_e_a_l_th__ o_f_P_u_e_r_t_o_Ri_ ._c_o _ Methods utiliz~d by the Department of Health for the Transportation of. Medicaid Recipients of Services: 1. · Transportation Services _will be· provided in Municipal and/or Department of Health ambulances including contract facilities for emergency cases, regardless of need. · 2. Categorically ·needy and Medically needy persons who can not afford to pay their traveling expenses for services provided under this plan, ·other than emergency.services, are eligible for emergency transportation ·services provided by the Department of Social Services~ 3. Transportation other than ambulance services is provided in public cars and other means of public transportation, according to fees established by the Public Setvice Conmtission, or at customary l~cal rates, whichever ·is ·applicable,. and paid usually by the municipality. -rN-#84-.3 approvlll dr.itL MAY 2 4 1985 SUfXfSede.s 4.J)Qc-hve dam ecr 1 t9s4 1'.N-# 7+1 OMB No. 0938-0193 Attachment 3 .1-E STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE I TERRITORY: COMMONWEALTH OF PUERTO RICO STANDARDS FOR THE COVERAGE OF ORGAN TRANSPLANT SERVICES Skin, bone, and corneal transplants are covered. All other organ and tissue transplants are not covered including (i) expenses brought about by such transplants of organs and tissues not covered in the State Plan, and (ii) hospitalization, complications, and chemotherapy related to transplants not covered in the State Plan. Maintenance prescriptions and required clinical laboratories for the continuity of a stable health condition, as well as any emergencies which could alter the effects of the previous procedure, are covered. Immnosuppressant drugs for all transplant patients are covered only to the extent of maintenance treatment post-surgery to ensure the continuity of health stability of the beneficiary, as well as emergencies that.may result after surgery (as transplants are not covered). Transmittal No.: 14~008 Effective Date: July l, 2014 Supersedes TN No.: NEW Approval Date: \~\\V\\, '-\ =» \. ' \' '· ~0 I l