Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act's (ACA) individual shared responsibility requirement.  Please visit the Internal Revenue Service (IRS) website at  www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and Plans available to you
• A health Plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other Plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee.  Self Plus One coverage is for the enrollee and one eligible family member.  Self and Family coverage is for the enrollee, and one or more eligible family members.  Family members include your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child under reaches age 26.

If you or one of your family members is enrolled in one FEHB Plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB Plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay. You can find additional information at www.opm.gov/healthcare-insurance.

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health Plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service Plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same Plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a Plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a Plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed Plans or Plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new Plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that Plan’s 2021 benefits until the effective date of your coverage with your new Plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member who is no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll. 

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHBP coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY:866-215-1999) from the U.S. Virgin Islands, or visit our website at www.ssspr.com.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times.  You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Your ID card does not have an expiration date to ensure the continuity of services and to avoid waiting for a new one.  Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands, or write to us at Triple-S Salud, Inc. (Triple-S Salud), Customer Service Department, 1441 Roosevelt Avenue, San Juan, Puerto Rico 00920. You may also request replacement cards through our website at www.ssspr.com.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments and/or coinsurances.  If you use our point-of-service program, you can also get care from non-Plan providers but it will cost you more. If you use our Open Access program you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

Plan facilities are hospitals  and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website.

Triple-S’s personnel is located at the hospitals in this network in order to provide you with educational material and coordinate services for you, such as:

• Admission process
• Precertifications
• Post discharge physician visits 

To know which in-network hospitals provide these services, refer to your provider directory.

Non-Plan Providers are physicians, medical groups or providers who do not have an active contracts with Triple-S but they are health professionals and providers of services which are covered by this plan. We reimburse members based on our established fees. 

You may refer to Section 1, How this plan works, under How we pay providers, for more information on reimbursement of non-plan providers.

Your general practitioner physician can be, for example, a family practitioner. Your physician will provide most of your healthcare, or refer you to a specialist.

If you want to change your general practitioner physician or if your general practitioner physician leaves the Plan, call us. We will help you select a new one.

Your general practitioner physician will refer you to a specialist for needed care. However, you may see any specialist without a referral.

Here are other things you should know about specialty care:

• If you are seeing a specialist and your specialist leaves the Plan, call us. We will provide you a list of specialists within your area. You may receive services from your current specialist until we can make arrangements for you to see someone else.

• If you have a chronic or disabling condition and lose access to your specialist because we:

- Terminate our contract with your specialist for other than cause;

- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or

- reduce our Service Area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

• If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan general practitioner physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB Plan to us, your former Plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former Plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your Plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new Plan begin on the effective date of enrollment.

FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Since your network physician arranges inpatient hospitalization and most referrals to specialists, the pre-service claim approval process only applies to care shown under Other services or out-of-network care when you self-refer. 

You must get prior approval for certain services. Failure to do so will result in a denial of service.

Your general practitioner physician may refer you for most services.  For certain services, your physician must obtain approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.  We call this review and approval precertification.  Call us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands.

We will provide benefits for covered services only when services are medically necessary to prevent, diagnose or treat your illness or condition.  You or your Plan provider must obtain precertification from this Plan for the following benefits or services:

• Services outside the Service Area, except emergencies; we will precertify services outside the service area, which will include payment determination, for those services that are not available in Puerto Rico;
• Chemotherapy drugs, radiation therapy, and genetic testing; 
• Rental and purchase of durable medical equipment;
• Skilled Nursing Facility;
• Organ and tissue transplants (see Note below);
• Lithotripsy;
• Osteotomy;
• Mammoplasty;
• Growth hormone therapy;
• Drugs identified with a precertification in the list of drugs;
• Positron Emission Tomography (PET AND PET-CT);
• Septoplasty;
• Rhinoplasty;
• Blepharoplasty;
• Office surgeries to be performed at hospitals;
• Surgical treatment of morbid obesity (bariatric surgery);
• Prosthetic tracheostomy speaking valve
• Tracheo-esophageal voice prosthesis
• Insulin pumps and/or their supplies
• Implant replacement; and,
• Treatment for lymphedemas, when the treatment is other than any physical complication after a mastectomy procedure.

Note:  There is a special prior approval process for transplant cases. To be considered for an organ/tissue transplant, members must:

• have a diagnosis indicative for transplant;
• have a medical history with recent documents including results of laboratories, tests and consultations; and
• meet the clinical criteria for the transplant. 

The referral can be sent thru fax 787-706-4018 / 787-774-4824 or by e-mail at manejocasos@ssspr.com to the Case Management Department.  All organ/tissue services require our prior approval for each transplant phase.

When you remain within our network, network providers will take care of precertification for you.  When you seek out-of-network care, your physician, your hospital, you or your representative, must call us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands before admission or services requiring precertification are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will tell the physician and/or facility the care that we approve for services that must have prior approval.  We will make our decision within 15 days of receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. 

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. 

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification. 

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands. You may also call OPM's Health Insurance 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

• HealthCare FSA (HCFSA)–Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children(through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

You do not need to precertify your normal delivery. If you are out of the area, please refer to Section 5(d) emergency benefits for information.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to do one of the following:

1.  Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply.

2.  Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 20% of our allowance for certain diagnostic tests.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

After your network copayments and coinsurance for covered services total $6,600 under a Self only enrollment, you no longer have to pay coinsurance or copayments for covered services that you receive within the network during that year. The out-of-pocket maximum under Self plus One or Self and Family is $13,200 combined for covered services that you and covered family members receive within the network but will not exceed $6,600 per member. 

The following services do not count toward your out-of-pocket maximum and you must continue to pay for these services:

• Difference between our Plan allowance and the billed charges for a covered service or supply; 
• Cost of non-covered services or supplies; and,
• Coinsurance you pay when you use non-Plan providers.

If you changed to this Plan during Open Season from a Plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that Plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.ssspr.com or contact the health plan at 787-774-6081.

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative benefit.  If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary.  Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review.  You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change).  You may request an extension of the time period, but regular benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Through Teleconsulta , members can have immediate access to the advice of professional nurses to help them decide whether to go to the emergency room immediately, visit or call their physician or follow self-care instructions to feel better. Nurses use scientifically based algorithms developed by physicians of all specialties to reach a recommendation for the member. Call us at 800-255-4375, toll free. We will be glad to assist you.

Triple-S Salud, Inc. is an independent concessionaire of the Blue Cross and Blue Shield Association. As in other Blue Cross and Blue Shield Plans, Triple-S Salud, Inc. participates in a program called the BlueCard Program. This program is of benefit for insured members who receive covered emergency or precertified services outside the service area of Triple-S Salud, Inc. through program plan providers.

When services are received outside the area and claims for such services are processed through the BlueCard Program, the amount (coinsurance, co-payment or deductible) paid for these services will be determined based on the arrangements as an estimate amount equivalent between the local Blue Cross or Blue Shield Plan of the area with its participating providers. The negotiated fee may be a discount of invoiced charges equivalent to an average of the savings that the area Blue Cross or Blue Shield Plan expects to receive from all or a specific group of its participating providers.

The BlueCard Program is available to all members insured with a Blue Cross and Blue Shield Association Plan. When you need emergency or precertified hospital and medical services in any state out of the service area, you can receive them through the Plan providers of this Program. Call 800-810-2583 or 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from U.S. Virgin Islands for additional information. Remember that you are responsible for paying the applicable copays or coinsurances related to out of area care according to the terms of your coverage.

We offer you the benefit of the Blue Distinction Centers for Transplants (BDCT) which is a cooperative effort among the Blue Cross and/or Blue Shield Plans, Blue Cross and Blue Shield Association and Participating Institutions to facilitate the provision of quality care in a cost-effective manner from leading institutions for six transplant types: heart, single or bilateral lung, combination heart-bilateral lung, liver, simultaneous pancreas-kidney, and bone marrow/stem cell (autologous/allogeneic). Call 800-981-4860 or 787-749-4949 extensions 4361 or 4312 for additional information.

Automatic interactive voice response unit that allows the member to access information and make transactions without a direct intervention of a Customer Service Representative. Through this system the member verifies benefits, asks for a duplicate ID card and verifies the status of a claim, among other services. Call us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 888-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands.

We offer a Medication Therapy Management Program at no additional cost to members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs.  This program was developed for us by a team of pharmacists and doctors.  We use this Medication Therapy Management Program to help us provide better coverage for our members.  For example, this program helps us make sure that our members are using appropriate drugs to treat their medical conditions and helps us identify possible medication errors.

We may contact members who qualify for this program.  If we contact you, we hope you will join so that we can help you manage your medications.  Remember, you don’t need to pay anything extra to participate.

If you are selected to join a Medication Therapy Management Program, we will send you information about the program, including information about how to access it.

We developed an HRA tool that evaluates lifestyles, risk factors, and existing conditions, among others.  It will help us have a clear profile of our insured population and help us determine where to direct our health education and prevention strategies.  The HRA will also help enrollees do a health-assessment to find out where they are in term of compliance with preventive tests, the changes they need to make, and to gain greater awareness to prevent future health problems. 

Once you complete your HRA, you will receive an Exercise Kit that includes a backpack with a water bottle, pedometer, wrist band, and jump rope.  Register today at our website www.ssspr.com.  Stay active, Stay healthy!

Get your medical checkups in a single visit.  You have more obligations every day but less time to accomplish them and healthcare is no exception.  The time it takes you to visit the doctor, get routine checkups and manage your existing conditions-in addition to the amount you spend on copays- are obstacles on your path to health.  Triple-S Salud, Inc. brings you the Preventive Care Program.  Members 21 years and older may receive all of their preventive services in one place! 

All around our Island you will find eight Preventive Care Centers located at:  Arecibo, Bayamón, Caguas, Carolina, Guaynabo, Mayaguez, Ponce, and San Sebastian.  In these facilities you will be able to receive services that include Evaluations, such as:  medical history, physical exams, depression screening, high-risk behaviors, and health education; Tests, such as:  CBC, cholesterol, Pap (cervical cancer), chlamydia, gonorrhea, syphilis, HIV, glycated hemoglobin, vision; Medical Referrals, such as:  Mammograms, vaccines, bone density test, colonoscopy, sigmoidoscopy, and much more.  Recommended tests and medical orders are based on clinical guidelines or medical criteria.

Oncology Analytics is a comprehensive oncology benefits management program which provides clinical decision support on oncology drugs, radiation therapy, molecular and genetic testing. Partnering with Oncology Analytics allows Triple-S to provide you with a higher quality of service by having clinical decision support by hematologists, medical and radiation oncologists, recommended protocols for efficacy, toxicity, and affordability and a user-friendly web-based application using the latest national guidelines.

Providers receive the clinical decision support necessary to make optimal treatment decisions for the most effective, affordable and least toxic care available. This optimizes outcomes and cost of care. Having access to evidence-based guidelines along with clinical depth and breadth of a clinical team ensures that you receive the highest quality value-based treatment decisions. Oncology Analytics applies evidence-based approach to preauthorization of chemotherapy drugs, radiation therapy, genetic testing and Pet CT, to reduce under-treatment, over treatment and inappropriate treatment of cancer patients.

Mobile application that will give access to send prescriptions electronically, buy medicine through the application and receive the order in your house or place of preference. 

For additional information, download the application into your mobile device or contact us at 888-525-4842.

A part of the approach to continue treating mental health conditions, the program will provide help for members, including:

• 24 hours Call Center fully attended by mental health professionals
• Immediate access to direct clinical face to face or virtual services
• Visits to EAP professionals, ten (10) visits per situation, per year
• FHC Emotional Connect-Teleheatlh: confidential way to timely access services to mental health specialist for counseling through videoconference
• Rehab Program
• Crisis Intervention

In most cases, providers and facilities file claims for you. Physicians must file on the form CMS-1500, Health Insurance Claim Form. Facilities will file on the UB-04 form. For claims questions and assistance, call us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands or visit us at our website at www.ssspr.com.

When you must file a claim - such as for services you receive outside of the Plan’s service area - submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the physician or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor --such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services
• For prescription drugs also include:
  • Prescription drug name;
  • Daily dosage;
  • Prescription number;
  • Dispensed supply; and
  • National Drug Code (NDC)

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Triple-S Salud, Inc.
PO Box 363628
San Juan, PR 00936-3628

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. 

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure. 

If you live in a country where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Triple-S Salud, Grievances and Appeals Department, PO Box 11320, San Juan, Puerto Rico 00922-9905; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write in English to OPM within:
• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620. 

Send OPM the following information in English:
• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health Plan or has automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one Plan normally pays its benefits in full as the primary payor and the other Plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.ssspr.com.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary Plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

We do not cover services that:

• you (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
• OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received. 

Reimbursement to us, out of the payment, shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Some FEHB Plans already cover some dental and vision services. When you are covered by more than one vision/dental Plan, coverage provided under your FEHB Plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision Plan on BENEFEDS.com or by phone at 877-888-3337, (TTY: 877-889-5680), you will be asked to provide information on your FEHB Plan so that your Plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial that is covered or is receiving standard therapy.  These costs are covered by this plan.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.  This plan does not cover these costs.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This plan does not cover these costs.         

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan - You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first.  In most cases, your claims will be coordinated automatically and we will then provide secondary benefits for covered charges.  To find out if you need to do something to file your claim, call us at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands, or see our website at www.ssspr.com.

We waive some costs if the Original Medicare Plan is your primary payor--We will waive some out-of-pocket costs, as follows:

• Medical Services and supplies provided by physicians and other health care professionals.  If you are enrolled in Medicare Part A and Part B we will waive copays and coinsurance. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

• Strips and lancets for members with Diabetes Type 1 and 2 that are enrolled in Medicare Part A and Part B. Medicare will be the primary payor and we will waive the Medicare deductible and coinsurance.

You can find more information about how our plan coordinates benefits with Medicare in our website at www.ssspr.com.

Please review the following information it illustrates your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

Benefit Description: Deductible
Member Cost without Medicare: $0
Member Cost with Medicare Part B: $0

Benefit Description: Out of Pocket Maximum
Member Cost without Medicare: $6,600 Self Only $13,200 Self Plus One and Family
Member Cost with Medicare Part B: $6,600 Self Only $13,200 Self Plus One and Family

Benefit Description: Primary Care Physician
Member Cost without Medicare: $7.50
Member Cost with Medicare Part B: $0

Benefit Description: Specialist
Member Cost without Medicare: $7.50
Member Cost with Medicare Part B: $0

Benefit Description: Inpatient Hospital
Member Cost without Medicare: $0
Member Cost with Medicare Part B: $0

Benefit Description: Rx
Member Cost without Medicare: 
Tier 1: Generic prescription drugs - $2.00 for unit or refill
Tier 2: Preferred brand prescription drugs - $20 for unit or refill
Tier 3: Non-preferred brand name drugs - 20% or $20, whichever is higher, up to $125 maximum out of pocket for unit or refill
Tier 4: Preferred Specialty/biotech drugs - 25% or $200 whichever is the lowest for unit or refill
Tier 5: Non-Preferred Specialty/biotech drugs - 30% or $300 whichever is the lowest for unit or refill
Member Cost with Medicare Part B: 
Tier 1: Generic prescription drugs - $2.00 for unit or refill
Tier 2: Preferred brand prescription drugs - $20 for unit or refill
Tier 3: Non-preferred brand name drugs - 20% or $20, whichever is higher, up to $125 maximum out of pocket for unit or refill
Tier 4: Preferred Specialty/biotech drugs - 25% or $200 whichever is the lowest for unit or refill
Tier 5: Non-Preferred Specialty/biotech drugs - 30% or $300 whichever is the lowest for unit or refill

Benefit Description: Rx – Mail Order (90 day supply)
Member Cost without Medicare: 
Tier 1: Generic prescription drugs - $4.00 for unit or refill
Tier 2: Preferred brand prescription drug - $40 for unit or refill
Tier 3: Non-preferred brand name drugs - 20% or $60, whichever is higher, up to a $375 maximum out of pocket for unit or refill
Member Cost with Medicare Part B: 
Tier 1: Generic prescription drugs - $4.00 for unit or refill
Tier 2: Preferred brand prescription drug - $40 for unit or refill
Tier 3: Non-preferred brand name drugs - 20% or $60, whichever is higher, up to a $375 maximum out of pocket for unit or refill

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage Plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage Plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage Plan, the following options are available to you:

This Plan and our Medicare Advantage Plan:  You may enroll in our Medicare Advantage Plan and also remain enrolled in our FEHB Plan.  We will still provide benefits when our Medicare Advantage Plan is primary, even when you visit non Plan providers of our Medicare Advantage Plan (but they are network providers of Triple-S Salud, Inc. regular Plan servicing FEHB). If you enroll in our Medicare Advantage Plan, please tell us.  We will need to know if you are enrolled in our Medicare Advantage Plan as soon as you subscribe to it, so we can correctly coordinate benefits with the FEHB Plan from the beginning of your Medicare Advantage coverage.

This Plan and another Plan’s Medicare Advantage Plan: You may enroll in another Plan’s Medicare Advantage Plan and also remain enrolled in our FEHB Plan. We will still provide benefits when your Medicare Advantage Plan is primary, even out of the Medicare Advantage Plan’s network and/or service area (if you use our Plan providers).  However, we will not waive any of our copayments or coinsurance. If you enroll in a Medicare Advantage Plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage Plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage Plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage Plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage Plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage Plan’s service area.

A provision in a health benefits claim form by which the insured directs the insurance company to pay any benefits directly to the provider of care on whose charge the claim is based.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, page 22.

See Section 4, page 22.

See Section 4, page 22.

Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a person not medically skilled, or that are designed mainly to help the patient with daily living activities. Custodial care that lasts 90 days or more is sometimes known as Long term care. These activities include but are not limited to:

• personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;
• homemaking, such as preparing meals or special diets;
• moving the patient;
• acting as a companion or sitter;
• supervising medication that can usually be self-administered; or
• treatment or services that any person may be able to perform with minimal instruction, including but not limited to recording temperature, pulse, and respirations, or administration and monitoring of feeding systems.

Services, drugs, supplies, or equipment provided by a hospital or covered provider of health care services that the Plan determines:

• are appropriate to diagnose or treat the patient’s condition, illness or injury;
• are consistent with standards of good medical practice in the United States;
• are not primarily for the personal comfort or convenience of the patient, the family, or the provider;
• are not a part of or associated with the scholastic education or vocational training of the patient; and
• in the case of inpatient care, cannot be provided safely on an outpatient basis.

The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug, or equipment does not, in itself, make it medically necessary.

In-network, network or plan providers are the Doctors, group of doctors, other health professionals, hospitals and other health care facilities that have an agreement with us to accept our payment and any copayment or coinsurance as a full payment. We have made some arrangements with these providers so they can offer services covered by our plan to our enrollees.

Doctors, group of doctors, other health professionals, hospitals and other health care facilities who do not have an active contract with Triple-S Salud, Inc. to accept our payment and any copay or coinsurance as a full payment.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows: the Plan allowance in our service area, Puerto Rico and U.S. Virgin Islands, is the medical benefits schedule, the fees Plan providers have agreed to accept as payment in full. The Plan allowance outside of the service area is the usual, customary and reasonable charge.

Advanced authorization from Triple-S Salud, Inc. for the payment of any of the benefits and coverage under this policy and its riders, in cases Triple-S Salud, Inc. deems necessary. Some of the objectives of the precertification are: evaluate if the service is medically necessary, evaluate the adequacy of the service location, verify the eligibility of the insured for the requested service, and its availability in Puerto Rico.  Precertifications will be evaluated based on the precertifications policies that Triple-S Salud,Inc. has set forth through time.  Triple-S Salud, Inc. will not be liable for payment of services that have been rendered or received without this authorization from Triple-S Salud, Inc.

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 787-774-6081 (TTY: 787-792-1370) from Puerto Rico or 800-716-6081 (TTY: 866-215-1999) from the U.S. Virgin Islands.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us, We and Plan refer to Triple-S Salud, Inc.

Network: $7.50 office visit copay for PCP or $7.50 specialist; Nothing for X-rays and $1.00 per laboratory
Out-of-Network: 10% of our allowance plus any difference between allowance and billed amount

25-26

Network: Nothing
Out-of-Network: 10% of our allowance plus any difference between allowance and billed amount

45

Network: $25 facility copay for outpatient surgery
Out-of-Network: 10% of our allowance plus any difference between allowance and billed charge

46

Network: Emergency room $25; if we recommend the visit $10. Nothing for hospital.

Urgent care in network urgent centers $10 copay

46

10% plus all charges that exceed our allowance

49

Regular cost-sharing

50-51

• Tier 1: generic prescription drugs, $2.00 for unit or refill.
• Tier 2: preferred brand prescription drug, $20 for unit or refill.
• Tier 3: non-preferred brand name drugs, 20% or $20, whichever is higher, $125 maximum out of pocket for unit or refill.
• Tier 4: Preferred Specialty/biotech drugs, 25% or $200, whichever is the lowest for unit or refill
• Tier 5: Non-Preferred Specialty/biotech drugs, 30% or $300, whichever is the lowest for unit or refill

54

• Tier 1: generic prescription drugs, $4.00 for unit or refill
• Tier 2: preferred brand prescription drug, $40 for unit or refill
• Tier 3: non-preferred brand name drugs, 20% or $60, whichever is higher, $375 maximum out of pocket for unit or refill

55

Nothing for diagnostic services; 30% all other services.

88

$7.50 per office visit

89

Flexible benefits option · Teleconsulta · Blue Card Program · Blue Card Worldwide · Centers of Excellence for transplants · Telexpreso · Medication Therapy Management Program · Health Risk Assessment (HRA) tool · Preventive Care Centers · Oncology Analytics

63-65