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Las exploraciones de análisis


Radiography of Medicaid and Medicare Advantage Population in Puerto Rico

Around 1.6 million people receive MEDICAID benefits in Puerto Rico

  1. There are 1.25 million participants of the Vital Healthcare Government Plan

  2. 295,000 of these are over 65 years of age, so they are also participants in the Medicare Platinum program (dual population)

  3. 1 in every 2 people in PR, almost 50% of Puerto Ricans, lives below Federal Poverty Levels

  4. Medicaid has the broadest coverage (medications, procedures, treatments, etc.) of all health plans.


Around 650,000 beneficiaries in Puerto Rico are enrolled in the MEDICARE ADVANTAGE program for the benefits it offers.

  • Medicare Advantage has a 94% penetration rate among eligible beneficiaries.

  • 40% of Medicare Advantage participants are older adults living below poverty levels, so they are also Medicaid participants.

  • Medicare Advantage has become the backbone of the health system on the island.

  • The population subscribed to Traditional Medicare is around 40,000 people with Part A and . This is 1% of the Medicare eligible population.


How does the disparity in Medicaid funding affect Puerto Ricans?

  • The Medicaid program in Puerto Rico receives over 50% less funds to serve beneficiaries who receive services through Plan Vital and over 90% less for Medicare Platinum beneficiaries.

  • In PR Medicaid covers ~$50 in monthly benefits while nationally the average is $1,650 monthly for dual eligibles

  • Benefits that are covered in the United States are not covered in Puerto Rico:

    • Platinum pharmacy benefits

    • Part B Payment to Platinums

    • Long Term Care (LTSS)


The cascading effect of this economic gap affects what beneficiaries receive monthly on their social security paychecks, as well as the level of compensation to providers.

En las Escalas
There are solutions that the U.S Congress and Federal Agencies can provide to help close the economic gap.

1. Setting a floor of 0.70 in the average geographic adjustment (AGA) factor. We need for the Department of Health and Human Services to mitigate, by means of an administrative fix, the persistent gap in MA base rates that keep Puerto Rico 21% below the rates of the US Virgin Islands and 39% below the national average. 

  • The current base premium is $672 per month in Puerto Rico and it could be increase to the same rate as in the U.S. Virgin Island, which is $847 per month

  • This increase would still keep us below the US average of $1,102 per month

  • If approved, it would be inject around $1.5 billion additional funds for the island


This is needed to address statutory inequities and data anomalies in Puerto Rico that have impacted the health care value and pricing structures for decades.  Puerto Rico would still be lower than any state but would be at par with the US Virgin Islands, a neighbouring territory with similar socio-economic circumstances. A proposal for this should be included in the 2025 MA Advance Notice being prepared now, in the fourth quarter of 2023.


2. Implementation of the Medicare Savings Program (MSP) in Puerto Rico

  • The Medicare Savings Program (MSP) is not applicable to residents of Puerto Rico, although it does apply to states and other territories.

  • As a result, the program takes about $164 a month from Social Security from the most vulnerable on the island to pay the Part B premium, which covers medical services.

  • This is almost $2,000 a year that our elderly poor pay for their health care.


It is disheartening that Puerto Rico is the only jurisdiction in the US where the local Medicaid program does not pay the monthly $164.90 Medicare Part B premium for the most vulnerable population, its dual-eligible beneficiaries.  All other duals in the U.S. mainland who are at or below 120% of the federal poverty level (FPL) receive this benefit.  


The Medicare Advantage (MA) plans in Puerto Rico have been offering partial help to pay for Part B, but it is not enough, and it takes away from the MA budget for provider compensation and other benefits.  The lack of MSP is particularly harmful to beneficiaries given other inequities like (a) the exclusion from the Supplemental Security Income (SSI) program, (b) the limited applicability of the Nutritional Assistance Program (NAP), and (c) the lack of Long Term Services and Support (LTSS) benefits.


3. Inclusion of Medicare Part D Low-Income Subsidy (LIS) to aid our most vulnerable populations and help them pay for their prescription drugs. 

  • The inclusion of the Medicare Part D Low Income Subsidy (LIS) program will help pay drug costs for low-income beneficiaries up to 150% above the Federal Poverty Level (FPL). in English).

  • This subsidy affects all dual-eligible beneficiaries - approximately 400,000 citizens in total.

  • This would represent an additional $700 million in benefits for this population.


The proposals to eliminate this exclusion of beneficiaries in Puerto Rico have been presented for many years, including by the Obama Administration ten years ago (HHS Report to the President’s Task Force on Puerto Rico, April 2013). Unfortunately, the Inflation Reduction Act of December 2022 extended the full Part D LIS benefits to 150% FPL but did not implement any change to the treatment of US citizens that reside in Puerto Rico.

Join us in our mission to improve healthcare in Puerto Rico. Contact us today to learn more about our services and how we can help you.

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