Your Rights
- Right to high quality health services.
- Right to get and disclose information.
- Right to choose plans and providers.
- Right to the continuity of health care services.
- Right to get emergency services and facilities.
- Right to take part in making decisions about your care.
- Right to respect and equal treatment.
- Right to privacy of your information and health records.
- Rights to file complaints and grievances.
- Right to communicate with the Puerto Rico Commissioner's Office (OCS) to report or dispute a charge outside the contracted network (Law 134 and Article 48.120 of the Puerto Rico Insurance Code).
Your Responsibilities:
- To give the information needed about health plans and the payment of any account. To know the rules of Coordination of Benefits.
- To give the most complete and accurate information, such as past illnesses, medicines, etc. To take part in all decisions about your health care. To know the risks and limits of medicine.
- To know the coverage, options, and learn health benefits and other details of the health plan (including access member assistance and ask questions about benefits).
- To follow your health plan administrative processes.
- To follow a healthy lifestyle.
- To let the doctors know of unexpected changes in your condition.
- To make known that you clearly understand the course of action suggested by the health professional.
- To give a copy of your advance directives.
- To let the physician known if you expect problems with the prescribed treatment.
- To know that the provider must be competent and fair when offering services to other patients.
- To be thoughtful, so that your personal conduct does not impact others.
- To solve any dispute through the processes set up by the insurance company.
- Let the insurer know of any case or suspicion of health insurance fraud.
Law 194 of August 25, 2000, “Letter of Rights and Responsibilities of the Patient”
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is "balance billing" (sometimes called "surprise billing")?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing”. This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
"Surprise billing" is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Puerto Rico Law No. 134 of September 1, 2020 “Law for the Protection of Patients from Surprise Medical Bills”, as well as local Law No. 194-2000 “The Patient’s Bill of Rights and Responsibilities”, as amended, provides that if you receive emergency services from an out-of-network provider, the provider that offers those services may not billed you in excess of any applicable deductible, copayment, or coinsurance for the services provided, according to your coverage. Any attempt by the provider to bill you in excess must be reported immediately to Triple-S Salud Customer Service Department.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may file a claim at the Office of the Insurance Commissioner of Puerto Rico.
Edificio World Plaza Phone: 787-304-8686
268 Av. Muñoz Rivera Toll Free:1-888-722-8686
San Juan, PR 00918 Fax: 787-273-6082
Piso 9 www.ocs.pr.gov
Visit www.dol.gov or www.cms.gov for more information about your rights under federal law.
For information on the payment dispute resolution process, visit: www.cms.gov/nosurprises or call 1-800-985-3059.
Law 134 of September 1, 2020 “Law for the Protection of Patients against Surprise Medical Bills”
