The Healthcare System in Puerto Rico: Medicare, Plan Vital, Private Insurance, Hospitals and Emergencies

Puerto Rico has no universal health insurance fund comparable to French Sécurité sociale. Protection rests on three tiers: US federal programmes, including Medicare for people aged 65 and over and Medicaid for low-income households, a health plan of the Puerto Rican government, the Plan Vital, and private insurance, individual or employment-based. The MACPAC commission counts Puerto Rico among the five US territories where Medicaid operates, with its own funding rules.

France Diplomatie describes the United States as having excellent but very expensive medical infrastructure, with no social security agreement covering health insurance between France and the United States. The Carte Vitale (the French health insurance card) therefore has no effect in Puerto Rico, and the French embassy covers no costs. Each situation (employee, retiree, student) has its own route: the page healthcare reimbursement in Puerto Rico details them one by one.

Medicare is for US citizens and qualified immigrants in legal residence aged 65 and over. According to the Centers for Medicare & Medicaid Services (CMS), those with at least 40 quarters of contributions (10 years for most people) receive Part A, hospital insurance, with no premium. Without enough quarters, it is possible to buy Part A for a premium, after enrolling in Part B, which imposes a five-year residence requirement on permanent residents.

The amounts published by CMS are revised each year: standard Part B premium (doctors, outpatient care) of the order of $200 per month, annual deductible and Part A hospital deductible per benefit period, and Part A premium of the order of $300 per month for 30 to 39 quarters of contributions or $550 per month below 30 quarters. A CMS fact sheet on Puerto Rico states that the Medicare Advantage programme, a formula offered by private insurers, covers hundreds of thousands of beneficiaries on the island, nearly half of them in plans intended for people eligible for both Medicare and Medicaid. The territory has no programme to help pay Medicare premiums comparable to that of the states, and the Extra Help assistance for Part D drugs is not available in Puerto Rico; Medicare.gov refers people with limited resources to other local programmes.

The Plan Vital is the health plan of the Puerto Rican government, administered by the Puerto Rico Health Insurance Administration (ASES). It provides physical and mental health services to about 1.6 million people (an undated figure on the ASES page) through four managed care organisations under contract, among which beneficiaries choose. Anyone can apply; the local offices of the Department of Health's Medicaid programme assess eligibility. The Medicaid call centre (787-641-4224) sets appointments, Monday to Friday from 8 a.m. to 6 p.m.

Federal Medicaid funding in the territories works with an annual cap, the section 1108 limit; beyond it, the territory funds its spending from local funds. According to the MACPAC commission, Puerto Rico's federal contribution rate is higher than its historical level of 55% and revised periodically. For a foreigner, immigration status matters: CMS points out that many qualified immigrants must wait five years before they can claim Medicaid. A French national holding a temporary visa or a recent residence card therefore arranges other cover during this period.

CMS states that residents of Puerto Rico cannot use the federal Marketplace to enrol in health coverage. For insurance bought individually, or through an employer whose activity is limited to Puerto Rico, the point of contact is the Commissioner of Insurance (OCS). The OCS publishes the list of insurers whose individual plans comply with the ACA and the Puerto Rico health insurance code (several insurers listed, excluding grandfathered plans); plans take effect every 1 January.

The cover of a locally recruited employee generally goes through their employer's insurance, which is part of the job offer (see working in Puerto Rico). Freelancers, students and retirees compare an individual policy approved by the OCS, the CFE (Caisse des Français de l’Étranger, the French overseas nationals’ health fund) and worldwide international health insurance whose coverage area includes the United States.

The emergency number is 911 throughout US territory (France Diplomatie). In Puerto Rico, the Centro Médico, located in the Monacillos district of Río Piedras (San Juan), is run by the Medical Services Administration (ASEM). Its trauma hospital is presented as the island’s only designated Level I institution and receives adult and child multiple-trauma patients, in coordination with emergency medical services. The ASEM emergency department is at the supratertiary level and also serves the US Virgin Islands and other eastern Caribbean islands. ASEM gives the switchboard number (787) 777-3535.

In an emergency, France Diplomatie specifies that the ambulance has priority on arrival at the hospital, but that admission is subject to a financial guarantee: insurance with direct payment avoids having to advance funds. For routine care, the choice of primary care doctor and their network depends on the contract (employer, Plan Vital, individual insurance); the list of approved practitioners should be requested from the insurer before the first consultation. The Plan Vital, run by ASES, directs its beneficiaries to the networks of its contracted organisations.

Medicines fall under Part D for a Medicare beneficiary, or under the contract of the insurance chosen. As Extra Help does not exist in Puerto Rico, people with limited resources turn to local programmes, including the Plan Vital for eligible beneficiaries. For an ongoing treatment, it is wise to arrange with your regular doctor the prescription and supply for the first months, then to check with the local insurer the list of reimbursed medicines and the co-payment required.

Dental and optical care follow their own rules depending on the contract: the page healthcare reimbursement covers them item by item. The reimbursements guide explains the basic notions of reimbursement and out-of-pocket costs.

Dengue. France Diplomatie reports a rise in dengue cases in Puerto Rico. The Department of Health has already declared public health emergencies after the epidemic threshold was exceeded; the CDC records thousands of confirmed cases each year, with a high proportion of hospitalisations and severe cases. The Dengvaxia vaccine has had its production discontinued (CDC). The symptoms resemble flu: fever, headache, aches. There is no curative treatment; France Diplomatie recommends seeing a doctor without delay and strictly avoiding anti-inflammatory drugs. Prevention rests on protection against mosquito bites.

Vaccinations. France Diplomatie asks for an up-to-date French vaccination schedule, in particular diphtheria, tetanus, polio, whooping cough and measles. Additional vaccinations may be indicated: tuberculosis for children under 15 in case of frequent or prolonged stays, chikungunya in case of an epidemic or prolonged stay, dengue in case of an active epidemic or prolonged stay in an endemic area, rabies for young children. The family doctor adjusts this list before departure. Natural risks (hurricanes from June to November, earthquakes) appear in the page living in Puerto Rico.

France Diplomatie considers it essential to hold, before any stay, an assistance policy or insurance that covers all medical costs, including surgery and hospitalisation, as well as medical repatriation. For a long-term move, cover is chosen according to status: employer insurance, approved individual policy, CFE or international insurance, then Medicare or Plan Vital when the conditions are met. The notions of first-euro cover, coverage ceiling and coverage area help to compare contracts; Expavy lets you test these guarantees against your situation.