(As stated in the Bill of Rights and Responsibilities of the Patient – Act No. 194-2000, as amended).
For the purposes of this law, these terms bear the following definitions:
- Bill — Refers to the “Bill of Rights and Responsibilities of the Patient”.
- Chiropractic physician or chiropractor — Refers to a professional that is licensed by the Board of Examiners of Chiropractors of Puerto Rico, as defined in Act No. 493 of May 15, 1952, as amended, also known as the “Act to Create the Board of Examiners of Chiropractors”.
- Clinical psychologist — Refers to the professional that is licensed by the Board of Examiners of Psychologists of the Commonwealth of Puerto Rico, as defined in Act No. 96 of June 4, 1983, as amended, also known as the “Act to Regulate the Practice of the Profession of Psychology in Puerto Rico”.
- Commissioner — Refers to the Commissioner of Insurance of Puerto Rico.
- Coverage — Refers to all the benefits included in a health care plan for its insured parties and beneficiaries.
- Department — Refers to the Department of Health of the Commonwealth of Puerto Rico.
- Guardian — The person who carries out guardianship duties, including legal guardians, individuals appointed by court or by a state or federal administrative agency, trustees, or previously appointed de facto guardians.
- Guardianship — Authority conferred in order to take care of a person and the property of a person who, due to them being underage or any other reason, lacks full legal capacity.
- Health care plan — Refers to any agreement whereby a person agrees to provide a subscriber, insured individual, or group of subscribers or insured individuals certain health care or health insurance services, either directly or through a provider; or to issue partial or total payment of the cost of such services in return for the payment of an amount predetermined in said agreement, which shall be considered as earned, regardless of whether the subscriber or insured individual uses or does not use the health care services provided by the plan. This includes health insurance plans, health care plans, or any other insurance contract of a similar nature, regardless of the insurer offering it.
- Health care facilities — Refers to all facilities identified and defined as such in Act No. 101 of June 26, 1965, as amended, known as the “Health and Social Welfare Facilities Act”, or pursuant to any future law on such matter.
- Health care professional — Refers to a practitioner that is duly licensed, according to the applicable laws and regulations, to practice any health and medical care profession in Puerto Rico, including but not limited to: physicians, surgeons, podiatrists, naturopathic physicians, chiropractors, optometrists, clinical psychologists, dentists, pharmacists, nurses, audiologists, and medical technologists, as authorized by the corresponding laws of Puerto Rico.
- Insurer — Refers to any person or entity, including health care service organizations, who is authorized by the Commissioner of Insurance to conduct insurance business in Puerto Rico and assumes a contractual risk in consideration of or in exchange for the payment of a premium. For the purposes of this chapter, the term Insurer also includes any non-pecuniary association, society, or mutual or friendly society or association that has established, and maintains and operates any medical, surgical and hospitalization service member plans in Puerto Rico, in consideration of the payment of a fee; or any entity involved in the business of granting insurance contracts or offering health care benefit plans.
- Medical emergency — Refers to a medical condition that manifests through acute symptoms of sufficient severity, including severe pain, where a reasonably prudent person with average knowledge of health and medical matters could expect that, without immediate medical attention, the individual’s health would be in serious danger, or that it could result in the severe impairment of any of the body’s extremities or organs; or to a pregnant woman feeling contractions, while there is not enough time to transfer her to other facilities before she goes into labor, or where transferring her would endanger the health of the woman or the unborn child.
- Naturopathic physician — Refers to a professional that is duly licensed by the Board of Examiners of Doctors in Naturopathic Medicine of Puerto Rico, as defined in Act No. 208-1997, as amended, known as the “Act to Regulate the Practice of Naturopathic Medicine in Puerto Rico”.
- Patient — Refers to any person who obtains or is liable to obtain health care treatment, either for a physical or a mental condition, and who consults with a health care professional or undergoes a test administrated by said person to obtain information that will help them stay in good health, obtain a diagnosis of their health condition, or treat an illness or injury affecting their health, including preventive diagnoses or treatments for the early detection of possible medical conditions or complications to conditions that have already been diagnosed, or to prolong the life and improve the quality of life of people with existing complications, regardless of whether or not they are subscribers or beneficiaries of a public or private health care plan.
- Sicólogo clínico — Significa el profesional licenciado por la Junta Examinadora de Sicólogos del Estado Libre Asociado de Puerto Rico, según definido en Ley Núm. 96 de 4 de junio de 1983, según enmendada, conocidas como “Ley para Reglamentar el Ejercicio de la Profesión de Sicología en Puerto Rico”.
- Person — Refers to any natural or legal person that is born, created or established pursuant to the laws of Puerto Rico.
- Premium — Refers to the remuneration paid to an insurer in exchange for assuming a risk through an insurance contract.
- Provider — Refers to a person or entity that is authorized by the laws of Puerto Rico to render or provide medical and hospital health care services in the Commonwealth of Puerto Rico.
- Secretary — Refers to the Secretary of the Department of Health of Puerto Rico.
- Terminal condition — Refers to a medical condition with a life-expectancy prognosis of six (6) months
- Ward — Person under the care of a guardian.
Rights – High-quality health care services
All patients shall have the right to receive health care services of the highest quality, consistent with generally accepted standards of medical practice.
Rights – Acquisition and disclosure of information
Concerning the acquisition or disclosure of information, any patient, guardian, user or consumer of medical and hospital health care services and facilities in Puerto Rico shall have the right to:
- Receive information that is true, reliable, timely and sufficient, easy-to-understand, and appropriate to their needs, regarding the health insurance plans and health care facilities and professionals they have selected or whose services they have requested, so as to be able to make well-informed and intelligent decisions regarding the plans, facilities, and professionals selected for themselves or their wards and the health care services they require.
- Receive adequate and sufficient information regarding the benefits covered by the health care plan; the premiums and deductible payments; the mechanisms and procedures to recover costs and resolve disputes; a list of the names and locations of participating facilities and professionals; the mechanisms and procedures for quality control and satisfaction assurance for the insured parties and beneficiaries; the procedures to obtain access to specialists and emergency services and the corresponding rules and procedures, including the plan’s institutional policy regarding health (care management).
- Receive adequate and sufficient information about the education, licensing, certification and re-certification of health care professionals; their years in practice; their experience in providing treatment or conducting pertinent tasks or procedures; reasonable treatment alternatives for diagnosed conditions or ailments, including their cost and likelihood of success; and the mechanisms and procedures for quality control and satisfaction assurance for their patients, users or consumers.
- Receive adequate and sufficient information from medical and hospital health care facilities regarding the personnel and technical resources available to conduct certain procedures and services; the education, training, and experience of the personnel available to administer said procedures or services; the mechanisms and procedures to recover costs and solve disputes; and the mechanisms and procedures for quality control and satisfaction assurance for their patients, consumers or users.
Rights – Plan and provider selection
As for the selection of health care plans and medical and hospital health care providers, all patients, consumers, or users of said plans and services in Puerto Rico are entitled to:
- An adequate and sufficient selection of health care plans and medical and hospital health care providers to guarantee access to high-quality health care, so that patients will be able to choose the health care plans and providers that best suit their needs and wishes, regardless of their socioeconomic status or their ability to pay. Patients under 19 years of age may choose the health care plan and providers that best suit their needs, without being discriminated against due to preexisting medical conditions or medical history. As of 2014, the right to not be discriminated against for a preexisting medical condition or medical history shall apply to all patients, regardless of their age.
- A network with sufficient authorized providers to guarantee that all services covered under the plan will be accessible and available with no undue delays and within reasonable geographical proximity to the homes and work places of the insured parties and beneficiaries, including access to emergency services twenty-four (24) hours a day, seven (7) days a week. All health care plans offering health care coverage in Puerto Rico shall allow patients to receive their primary health care services from any participating primary health care provider chosen by the patient, pursuant to the provisions contained in the health care plan.
- All health care plans must allow patients to receive specialized health care services as necessary or appropriate to maintain their health, according to the procedures for referrals under the health care plan. This includes access to specialists qualified to provide health care services to patients with special health conditions or needs, in order to guarantee the insured parties and beneficiaries a direct and speedy access to the qualified providers or specialists they have chosen from among those in the plan’s network of providers to meet such health care needs. In the event that the plan requires special authorization to have access to qualified providers or specialists, the plan shall guarantee an adequate number of consultations to cover the health care needs of the insured parties and beneficiaries.
- Select and have access to the health care services and treatments offered by podiatrists, chiropractors, optometrists, audiologists, or naturopathic physicians, if the coverage provided by their health care plan offers services included under the “spectrum of practice” of licensed podiatrists, chiropractors, naturopathic physicians, optometrists, audiologists and clinical psychologists licensed and authorized by the Commonwealth of Puerto Rico. If the patient’s coverage or plan provides compensation or reimbursement, the beneficiary and the podiatrist, chiropractor, naturopathic physician, optometrist or clinical psychologist rendering the services shall be entitled to said compensation or reimbursement under equal conditions to that of any other health care professionals providing the same services.
- Every public and private medical and hospital facility shall allow its patients to choose and have access to health care services and treatments provided by a podiatrist, if available, and shall include the services of said provider as part of their medical faculty, after the provider undergoes evaluation by the hospital’s credentials committee in the same manner as any other specialized doctor of the institution, without discriminating as to professional class. To be included in a medical faculty, podiatrists are required to have completed a medical and podiatric surgery residency accredited by the Council on Podiatric Medical Education and the American Podiatric Medical Association. The clinical and surgical privileges of said physicians shall be granted based on education, training and expertise, as well as individual experience and the recommendations made by the American College of Foot and Ankle Surgeons.
- Have health care plans offer them coverage, without dollar limits, as defined by federal law and corresponding federal regulations, either for life or through annual contract, for essential health benefits as defined in Public Law 111-148, known as the Patient Protection and Affordable Care Act, its regulations, and the rules established by the Commissioner.
- Have health care plans include, as part of their basic coverage and without any additional costs or copays, the following preventive health care services: the preventive care recommended by the United States Preventive Services Task Force; the immunizations recommended by the Advisory Committee Immunization Practices of the Centers for Disease Control and Prevention; for infants, children, and adolescents, up to 21 years of age: preventive care that includes the recommended immunizations according to their age; and for women: preventive care against breast cancer, as recommended by the Health Resources and Services Administration. These are the minimum requirements, and they are not to be construed as a limit for insurers to offer greater coverage.
- Have health care plans including dependents as part of their coverage to extend such coverage to unmarried dependents up until 26 years of age. The Commissioner shall regulate these cases and their application.
- Have individual and group health care plans cover direct access to gynecology and obstetrics services, without requiring referrals or the plan’s prior authorization, insofar as said physician is part of the health care provider network.
- Have individual or group health care plans covering minors as participants or beneficiaries to allow the parent or tutor of the dependent minor to select a pediatrician as his/her primary health care provider, insofar as said pediatrician is part of the health care provider network.
- Have individual or group health care plans implement an internal claims system approved by the Commissioner, to provide adequate and reasonable procedures to promptly settle disputes over the determinations for the coverage and claims of insured parties. Plans shall notify their insured parties that they have access to an appeals procedure; that they have the right to be assisted by a government official, such as the Advocate for Patients, the Ombudsman, or an attorney of their choice; that they have access to their medical records; that they may submit written or oral evidence; and that they have the right to receive benefits, as determined during the process. Insured individuals shall have the right to have health care plans establish an appeals system before an external independent entity that meets such requirements as established by the Commissioner. All insured parties have the right to an expeditious evaluation process in case of an emergency where their health is at risk.
Rights – Continuation of health care services
All patients, consumers or users of medical and hospital health care services in Puerto Rico are entitled to:
- Have health care plans include a provision in their contract or policy stating that such health care plans may not be rescinded or amended, once the beneficiaries are covered under such plans or included in the coverage, unless they: default on the payment of their premiums and do not comply with the grace periods granted by the Insurance Code; have performed an act that constitutes fraud; or makes an intentional misrepresentation, as prohibited by the plan, of material facts or important matters to accept the risk or for the risk assumed by the insurers.
- Health care plans shall contain a clause providing that, if the health care plan or provider coverage is terminated or cancelled, the insurer shall notify the patient of such termination or cancellation thirty (30) calendar days before the effective date of such termination or cancellation.
- Subject to any premium payment requirement, all health care plans must contain a clause providing that, should the plan or provider terminate coverage, the patient may continue receiving the benefits thereof for a transitional period of ninety (90) days as of the date the plan or provider terminates coverage.
- If the patient is hospitalized at the time of the plan’s termination date and the patient’s release date was scheduled before the date of termination of coverage, the transition period shall be extended from such date to ninety (90) days after the date the patient is released.
- If the patient is in her second trimester of pregnancy as of the plan’s termination date, and the provider has been offering medical treatment pertinent to the pregnancy before the coverage termination date, the transitional period concerning pregnancy-related health care services shall be extended to the date the mother is released from the hospital after childbirth or the date the newborn is released from the hospital, whichever occurs later.
- If the patient is diagnosed with a terminal condition before the plan’s termination date and the provider has been offering medical treatment pertinent to the condition before such date, the transitional period shall be extended for the remainder of the patient’s life.
Providers that continue treating the insured parties or their beneficiaries during said period must accept the payments and rates established by the plan as full payment for the services rendered, they must continue providing the plan with all the information required for the purpose of quality control, and they must surrender or transfer the patient’s medical records upon termination of the transitional period.
Rights – Access to emergency services and facilities
All patients, consumers, and users of medical and hospital health care services in Puerto Rico are entitled to:
- Have free, direct and unrestricted access to emergency services and facilities whenever and wherever the need may arise for such services and facilities, regardless of their social or financial status or their ability to pay. No health care plan may refuse payment or coverage for emergency medical and hospital health care services to any insured party or beneficiary.
- Health care plans shall provide their insured parties and beneficiaries, or alternatively their guardians, with reliable and thorough information concerning the availability, location, and proper use of emergency services and facilities in their respective area, as well as any provisions concerning premium payments and refunds for costs related to said services, and the availability of comparable medical care outside said emergency facilities and services.
- All health care plans in Puerto Rico shall provide emergency service benefits with no waiting period. Prior authorization from the insurer shall not be required when providing these emergency services; furthermore, these services shall be provided regardless of whether the emergency service provider is a participating provider. If a patient receives services from a provider not contracted by the insurer, the patient shall not be held liable for the payment of services in an amount exceeding the applicable amount if the patient had received such services from a provider contracted by the insurer. The insurer shall compensate the provider offering the services, and the provider shall be under the obligation to accept said compensation, for an amount no less than what was agreed with the providers contracted by the insurer to offer the very same services. Moreover, under these circumstances, such emergency services shall be provided regardless of the conditions set forth by the corresponding health care plan.
- If the patient receives health care services after receiving emergency or post-stabilization services, which would be covered under the health care plan, except when a nonparticipating provider is involved, the insurer shall compensate the patient for the portion of the costs for said services that would have been paid under the plan’s arrangement, provided that there are sound medical reasons for which the patient cannot be transferred to the care of a participating provider.
- The personnel rendering services at an emergency facility shall contact the patient’s primary care physician, should the patient have one, as soon as circumstances allow for the discussion of follow-up treatment to that which was administered to the patient at said facility, the post-stabilization care given to the patient, and the continuation of services, if any, as required by the patient.
Rights – Participation in the decision-making process regarding treatment
All patients, guardians, consumers, or users of medical and hospital health care services in Puerto Rico are entitled to:
- Have full participation in all decisions concerning their medical and health care, including the right to choose and demand that their foot conditions be treated by a podiatrist. In case of patients with diabetes or other chronic conditions, they should request a previous evaluation by an endocrinologist, nephrologist, or a specialist in the corresponding medical field. In the cases of patients, consumers, or users of medical and hospital health care services who are unfit to fully participate in the decision-making process regarding their medical and health care, such patients, consumers, or users shall have the right to be represented in said decision-making process by either one of their parents, their tutor, custodian, guardian, or spouse; a relative; or a legal counsel, proxy, or any person appointed by court for such purposes.
- All physicians and health care professionals shall provide their patients with sufficient and appropriate information, as well as the real opportunity to substantially participate in the decisions concerning their medical and health care, in such way that patients will be able to offer their consent in said decisions, including but not limited to the discussion of treatment options in a manner comprehensible to the patients and the option to refuse or not receive any treatment at all; along with the costs, risks, and chances of success for each treatment option, or for no treatment at all; and the patient’s future preferences in case they lose their capability to validly state their consent concerning the various treatment options.
- Give advance directives or guidelines regarding their treatment, or appoint a person to act as their guardian, if necessary for the decision-making process. All physicians or health care professionals shall discuss with their patients and the patients’ relatives the matter of using such advance directives or guidelines to state their preferences, including but not limited to the use of powers of attorney or living wills. The provider shall honor these wishes to the extent they are allowed by law.
- All physicians or health care professionals shall respect and abide by the decisions and preferences stated, either in written or spoken form, by their patients or their guardians concerning the treatment options discussed with them.
- All physicians, health care professionals, and health care plans shall provide their patients, guardians, insured parties, and beneficiaries with sufficient and adequate information regarding any factors, including payment methods and rates, as well as their properties, shares, or stakes in health care facilities and medical and hospital health care services, that could influence their recommendations for treatment options or alternatives.
- All health care plans shall ensure that their contracts with medical and hospital health care providers are free of any gag order clauses, penalty clauses, or any other contractual mechanisms that may impair the provider’s ability or capability to contact said insured parties, beneficiaries, or their guardians to discuss all available treatment options and to make specific treatment recommendations according to the professional opinion and judgment of said providers.
- All health care plans shall contain a provision stating that the insurer shall cover the routine medical expenses for any patient suffering from a life-threatening condition for which there is no effective treatment, as long as the patient is eligible to participate in an authorized clinical trial for treatment, pursuant to the clinical trial’s provisions for said treatment, and provided that the patient’s participation offers a potential benefit to the patient, that the referring physician believes that participation in said trial is pertinent, or that the patient presents evidence that participating in said trial is adequate. “Routine medical expenses for any patient” shall not be construed to be expenses related to the clinical trial or administered tests to be used as part of the trial, or the expenses the entity conducting the trial is liable to pay.
- All physicians or health care professionals shall provide their patients, or their guardians, with prescriptions for laboratory tests, X-rays, or medications in such a way that the patient will be able to freely select the health care facility where they will receive these services.
Rights – Respect and equal treatment
All patients, consumers, or users of medical and hospital health care services in Puerto Rico have the right to be treated equally, courteously, and respectfully by all members of the health care industry, including but not limited to health care professionals, health care plans, and health care facility operators and providers, at all times and under any circumstances. No patient, consumer or user of medical and hospital health care services shall be discriminated against due to the public or private nature of such service facilities or providers, or due to race, color, sex, age, religion, ethnic origin or background, nationality, political ideology, present or future physical or mental disability, medical or genetic information, social status, sexual orientation, ability to pay, or means of payment of the consumer or user of said services and facilities.
Rights – Confidentiality of medical records and information
All patients, guardians, consumers and users of medical and hospital health care services in Puerto Rico have the right to:
- Communicate freely, at ease, and in strict confidentiality with their medical and hospital health care providers.
- Feel fully confident that their medical and health information will be kept in strict confidentiality by their medical and hospital health care providers, and that said information will not be disclosed without written consent from the patients or their guardians, and in any case, solely for medical or treatment purposes, including the continuation or modification of medical care or treatment, for prevention, for quality-control purposes, or in regards to the payment of medical and hospital health care services.
- Feel confident that the unauthorized disclosure of information contained in medical or health records will be made only after a court order has been issued or when specifically authorized by law, including but not limited to investigations concerning the perpetration of fraud or crimes.
- All providers and insurers are to keep the confidentiality of all files, clinical records, or documents containing information on the medical status of any patient. All providers and insurers shall also take measures to protect the privacy of their patients and safeguard their identity. Nothing provided in this chapter shall be deemed to impair the exchange of information between health care providers and the Puerto Rico Health Insurance Administration, when such information is provided for auditing or service payment purposes. The beneficiary acknowledges the power of the Puerto Rico Health Insurance Administration to initiate collection and recovery efforts for premium payments.
- Every provider and insurer shall provide all patients, or their guardians, quick access to their files and records. Patients have the right to receive a copy of their medical record. Whenever any of the parties, to wit the medical service provider or the patient, concludes the physician-patient relationship, said medical record shall be submitted to the patient, father, mother, or tutor, free of charge, within a term not exceeding five (5) working days. If there is an outstanding debt between the physician and the patient, this shall not be an impediment for the patient to obtain his/her medical record.
- To obtain a receipt for all expenses incurred when issuing partial or full payment of the deductible or others, at the time of making such payment. Said receipt shall include at least the following information:
- Name of the medical-hospital institution, license number, and specialty.
- Date the service was rendered.
- Name of the patient or service consumer.
- Name of the person who paid for the services, if different from the person who received them.
- Amount paid for the service.
- Signature of authorized official at the medical or hospital institution.
- To receive a quarterly detailed breakdown of the services and general expenses incurred, whether from the insurer, the insuring entity, the health care facility, the Puerto Rico Government Health Plan, or the health care plan. This report shall be delivered only to the insured person, and it shall be sent securely to the email address provided by the insured person or subscriber, or through the employer that negotiated the group coverage. The insured person may request to receive this report by mail. The insured person or subscriber shall be responsible for notifying any change of e-mail or mailing address to the insurer, the health care facility, the Puerto Rico Government Health Plan, or the health care plan. Any person under obligation to send the report who fails to do so because he/she has an incorrect, nonexistent, or incomplete address, or has had the report returned previously, or has an address that does not meet the criteria established by the United States Postal Service, shall not be guilty of violating the law. The report shall include at least the following information:
- Name of the insured person or subscriber.
- Total premium payment.
- Date of service.
- Type of service.
- Description of service.
- Service provider.
- Amount paid by the insured person.
- Amount paid by the insurer.
- Total amount paid.
Rights – Complaints and grievances
All patients, consumers and users of medical and hospital health care services in Puerto Rico have the right to:
- Be afforded simple, fair, and effective mechanisms or procedures to settle any differences with their health care plans, health care professionals, and medical and hospital health care facilities and providers, as well as the assurance that said mechanisms and procedures include internal quality controls and external oversight to guarantee their reliability and efficiency.
- Be afforded internal mechanisms or procedures for appeals concerning said institutional health care plans or providers, including the timely written notice of any decision denying, limiting, or terminating services or refusing the payment of services, as well as the grounds or basis for such denial, limitation, or termination, and the mechanisms and procedures available to appeal such decision.
- Prompt and timely settlement of all appeals filed by said consumers or users, including the speedy resolution of cases concerning urgent or emergency care, within the scope or standards required by Medicare.
- Have their claims reviewed by duly qualified and fully accredited health care professionals who are trained in the field of the treatment in question and have not taken part in the initial decision for which a review has been requested.
- Receive final written notice of the decision for which a review has been requested by the patient, consumer, or user, including the basis or grounds supporting said final decision and the external mechanisms or remedies available by law to appeal said decision before an external entity.
- Simple, fair, and affordable mechanisms or procedures to settle any differences in matters such as waiting periods, operating hours, performance of the personnel serving the public, and the state and conditions of the facilities.
- Any external system of appeals provided by a health care plan or provider shall be available only in cases where consumers or users have exhausted all internal remedies. Said system shall be under the management of duly qualified and fully accredited health care professionals who are trained in the field of the treatment in question and have not participated in the initial decision for which the review has been requested. Said system shall follow reviewing standards based on the submitted proof and objective medical evidence. The system shall settle appeals in a fair, efficient and timely manner; and it shall apply to any decision to deny, limit or terminate service coverage or payment on the grounds that the treatment in question is at an experimental or research stage, or is not medically necessary and exceeds reasonable costs, or endangers the life or health of the patient.
- Guardians shall acquire all patient-ward rights conferred by this section.
Responsibilities of patients, consumers, or users of medical and hospital health care services and facilities
The vital nature of health care calls for patients, consumers, or users of medical and hospital health care facilities, as well as their guardians and relatives, to participate in their care. However, patient satisfaction and health care effectiveness is partially contingent upon the patients’ adequate fulfillment of their responsibilities. These responsibilities are, among others:
- Patients are responsible for providing, to the best of their knowledge, complete and accurate information regarding their present health condition, past illnesses, medications, hospitalizations, and other related matters.
- Patients are responsible for reporting unexpected changes in their conditions to the health care professional in charge of their treatments.
- Patients are responsible for informing that they clearly understand the course of action expected of them.
- Patients are responsible for providing copies of their written advance directives or guidelines, if any, stating their wishes concerning future medical treatment to extend their lives.
- Patients are responsible for informing their health care providers if they foresee any problems with the prescribed treatment.
- Patients are responsible, as community members, for knowing that providers are under the obligation to be efficient and fair in providing care for other patients.
- Patients and their relatives are responsible for making reasonable arrangements so their particular actions will not affect the needs of the hospital, other patients, the medical staff, or other employees.
- Patients are responsible for furnishing any necessary information about their health care plan, and for collaborating with their providers regarding their respective financial arrangements, when necessary, for the timely payment of all accounts and bills issued to the patients.
- Patients are responsible for being aware of the effect their lifestyle has on their health, and for assuming the initial personal responsibility for their own health and care. Patients themselves shall assume the responsibility of preserving their health and looking after their relatives.
- Patients are responsible for participating in all decisions concerning their care.
- Patients are responsible for notifying pertinent authorities of any fraud or inappropriate actions they are aware of, concerning medical and hospital health care services and facilities.
- Patients are responsible for employing the internal mechanisms and procedures established by health care providers or health care plans to settle their differences.
- Patients are responsible for recognizing the risks and limits of medicine and the fallibility of health care professionals.
- Patients are responsible for being well-informed concerning their health care plan, in terms of type of coverage, options, benefits, limitations, exclusions, and referrals, as well as procedures to file, review, and settle complaints.
- Patients are responsible for complying with the administrative and operational procedures set forth by their health care plans, their health care providers, and government health benefit programs.
- Guardians shall acquire all patient-ward responsibilities conferred by this section.
The responsibilities of patients set forth in this section shall be interpreted on a case-by-case basis, considering the patient’s education and social and financial status in benefit of the patient. These responsibilities shall not be construed to be a limitation on the exercise of the powers conferred under the section “Effect on other laws and regulations” of this Bill.
Faculties and responsibilities to implement this Bill
The Department of Health shall be responsible for implementing the provisions in this Bill. To this end, it will adopt and enact the necessary regulations for said purposes, including but not limited to the mechanisms to submit, arrange, and solve complaints and grievances.
Requirement of statement by users or consumers
All insurers, health care plans, health care professionals, and medical and hospital health care providers authorized to conduct business as such in Puerto Rico shall require and demand from all their patients, insured parties, or service users or consumers—or in the case of disabled or underage persons: from the parents, guardians, custodians or tutors of said persons—that, before signing any contract, they read and become familiar with the “Bill of Rights and Responsibilities of the Patient” or a suitable and reasonable summarized version thereof, as prepared or authorized by the Department of Health. As proof that this requirement has been fulfilled, the insurers, health care plans, health care professionals, and medical and hospital health care providers shall also require from all patients, insured parties, or medical and hospital health care service users or consumers who are contracting their services—or in the case of disabled or underage persons: from the parents, guardians, custodians, or tutors of said persons—that, before signing any contract, they sign a written statement or release attesting that they received a copy of, and have read and are familiar with, the “Bill of Rights and Responsibilities of the Patient”, or a summarized version approved by the Department of Health.
Complaints and related procedures
- All patients, guardians, insured parties, consumers, or users of medical and hospital health care services and facilities who deem that their rights or those of their wards have been violated under this Bill may file an administrative complaint with the Department against the provider or insurer in question, concerning matters such as:
- The patient has not been provided with communications written in Spanish or English, according to the patient’s request.
- The patient is not receiving health care services of a quality consistent with the generally accepted standards of medical practice.
- A provider refuses to provide emergency services that should be covered pursuant to this Bill; or an insurer has refused to cover such services, or pay the provider that rendered such services, or reimburse the amount paid by the patient for services that the insurer is required to reimburse.
- An insurer refuses to authorize a change of primary health care provider, as requested by the patient.
- A provider or insurer interferes with a patient’s right to have access to specialized health care services.
- An insurer refuses to continue health care coverage during the transitional period as required by this Bill.
- An insurer refuses to cover the routine medical expenses for a patient undergoing clinical trials, which should be covered pursuant to this Bill.
- An insurer does not have a suitable infrastructure to provide health care services, including specialized services.
- A provider or insurer has acted discriminatorily against a patient due to race, ethnic background, national origin, religion, sex, age, social background or status, political ideology, mental or physical condition, sexual orientation, genetic makeup, and source or means of payment for the health care services.
- An insurer or provider has disclosed patient information in violation of this Bill, or failed to take measures to protect the patient’s right to privacy.
- A provider refuses to supply information to the patient regarding the health care services the patient will receive, or the provider does not furnish comprehensible information on the matter.
- An insurer fails to inform the patient about the health care services covered under the insurer’s health care plan as required by this Bill.
- A provider restricts communication with the patient, without notifying the patient of the grounds for such restriction.
- Once the complaint is filed with the Department, the Department shall determine whether the matter being brought for consideration falls under its scope of jurisdiction or under that of the Commissioner or the Health Insurance Administration, after which the Department shall make a referral, as it deems pertinent. It is understood that the matters under the jurisdiction of the Commissioner are those involving disputes over coverage or rights deriving from provisions set forth in a health care plan or, without it constituting a violation of rights under this chapter, disputes involving inappropriate conduct or unfair practices by an insurer, pursuant to the Puerto Rico Insurance Code. It is understood that matters under the jurisdiction of the Puerto Rico Health Insurance Administration shall be the cases with corresponding procedures pursuant to Act No. 72-1993, as amended, known as the “Puerto Rico Health Insurance Administration Act”. In all other cases, the Department shall process the complaint.
The Department of Health, the Health Administration, and the Office of the Commissioner of Insurance of Puerto Rico shall be empowered, as part of the complaint procedures, to impose fines as authorized under Act No. 170 of August 12, 1988, as amended, known as the “Commonwealth of Puerto Rico Uniform Administrative Procedure Act”. All complaints shall receive immediate attention.
Effect on other laws and regulations
None of the provisions in this Bill shall be construed to be excluding, curtailing, limiting, undermining, or otherwise impairing the rights of any natural or legal person to claim or file any rights, remedies, causes of action, or proceedings as granted, recognized, or allowed under other criminal, civil, or administrative laws or regulations before the pertinent judicial or administrative forums.
All insurers, health care plans, health care professionals, or medical and hospital health care providers who do not comply with any of the responsibilities or obligations established in this chapter, shall be guilty of an administrative fault and sanctioned with a fine of no less than five hundred dollars ($500) and no greater than ten thousand dollars ($10,000), for each incident or law infringement.
- The parents, children of legal age, custodians, guardians, spouses, relatives, legal representatives, proxies, or any other person appointed by court or by the patients themselves, shall be able to exercise these rights if the patients are not capable of making decisions, are declared legally incompetent, or are underage.