Application for the government medical plan

What is the Government Medical Plan?

• It is the health plan that the government of Puerto Rico grants through federal Medicaid funds.
• This plan must meet the health needs of the population with limited economic resources or special needs.
• At this time, it is in the hands of 5 private health providers but it is administered by the government of Puerto Rico.
• Benefits people who have no way to pay for a health plan.
• It guarantees access to services and their insurers, as well as medical-hospital benefits.

Is this plan for everyone?

No, this plan is for anyone who has been approved as eligible by the Medicaid program. Medicaid will only take into consideration the economic reality of the person and their family and may NOT discriminate based on race, age, sex, nationality, or religious belief. Depending on the income of the family, Medicaid will impose a copayment (an amount that must be paid to receive the medical service).

• If the medical person or provider of services is within the Group of Primary Physicians authorized to the person by his Plan, he will have low-cost copays or will not have to pay copays
• If the doctor or provider is NOT within your Authorized Primary Physician Group, you will need a referral from your primary physician
• You have to pay the established copay
• If you do not agree with the copayment that is required, you can request a revaluation at (787) 641-4224

Who provides health services in Puerto Rico?

The plan is offered by 5 private health companies that operate in Puerto Rico, but the plans are administered and evaluated by the Government through the Health Insurance Administration in Puerto Rico. The companies are:

• Triple S, Health
• First Medical Health Plan (FMHP)
• Molina Healthcare
• Mennonite Health Plan (PSM)
• MMM MultiHealth

Annual Enrollment Period

The Vital health plan of the Government of Puerto Rico allows beneficiaries to change their insurer once a year in a designated period. Within a said period, the beneficiary can choose the insurer of his or her preference from the aforementioned list of participating insurers.

After the period has expired, the person can still change insurer but only if they can show “just cause” for not having changed insurer within the official period. For further guidance regarding this annual enrollment period and what constitutes “good cause,” we suggest that you contact the Life Guidance Center at 1-833-253-7721 or 1-800-981-2737.

How do I apply?

You can apply for a Government Medical Plan. The most efficient way is through the internet or by calling the Medicaid Program line at (787) 641-4224

To apply online, you can visit the following page: https://www.medicaid.pr.gov/

In the following video you can see the steps to follow to apply online:

If you decide to apply by phone, they will give you an orientation about the documents you must bring (these vary) and they will make an appointment for an initial interview. 

The initial appointment will be made in the town where the applicant resides and the documents that had been required in the telephone call will be evaluated. It is important to arrive at the appointment 15 minutes before the established time.

The person will know at the end of the appointment if their request was accepted or not. If it is not accepted, you will receive a notice of action in 7 to 10 days with the decision and the reason for denying the request.

• You can request a reevaluation by calling (787) 641-4224
• Call in the next 10 days and ask for a new appointment

If the request was approved, you will receive a medical plan card within 7 to 10 days. This includes:

• The contract between the applicant and the private medical plan where is explained when the Plan begins to run and when it ends.
•  They will also send you a pamphlet with the name of the doctors and the facilities where you should seek services.
• At the time of the appointment, you will be given your MA-10 which can ONLY be used in emergency rooms (it is a sheet that attests that you have a medical plan)
• You will NOT be able to use any medical services other than the emergency room before you receive your card