This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Triple-S Salud, Inc. holds the URAC accreditation. To learn more about this plan’s accreditation(s), please visit the following websites: www.ssspr.com. We require you to see those physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
Benefits offered under this Plan may be modified by Triple-S Salud, Inc. to authorize payment for treatment methods or therapies not expressly provided for but not prohibited by law or rule if otherwise that method or therapy is as cost effective as providing benefits to which the enrollee otherwise is entitled.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments and coinsurance described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the Plan’s benefits, not because a particular provider is available. You cannot change Plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
Who provides my health care
Triple-S Salud, Inc. is an individual practice prepayment Plan. You can receive care from any Plan provider. A Plan provider is a doctor of medicine (M.D.) licensed to practice in the Commonwealth of Puerto Rico or in the U.S. Virgin Islands, who has agreed to accept the Triple-S Salud, Inc. established fees as payment in full for surgery and certain other services. If you use a non-Plan provider, you must pay in full for the services rendered and Triple-S Salud, Inc. will reimburse you based on the established fees. A non-Plan provider is any licensed doctor of medicine (M.D.) who is not a Plan provider. Non-Plan providers do not have to accept Triple-S Salud's established fees as payment in full. Most doctors practicing in Puerto Rico are Plan providers.
You can also receive services from a Plan hospital. This is a licensed general hospital in Puerto Rico or the U.S. Virgin Islands that has signed a contract with Triple-S Salud, Inc. or Blue Cross Blue Shield to render hospital services to persons insured by Triple-S Salud, Inc. A non-Plan hospital is any licensed institution that is not a Plan hospital and that is engaged primarily in providing bed patient with diagnosis and treatment under the supervision of physicians with 24-hour-a-day registered graduate nursing services. You must pay any difference between the non-Plan hospital’s charges and the amount paid to you by Triple-S Salud, Inc.
Benefits for services you receive in Puerto Rico or U.S. Virgin Islands are paid according to the “medical benefits schedule” of Triple-S Salud, Inc. in Puerto Rico and in the U.S. Virgin Islands. This is the schedule of established fees on which this Plan’s payment of covered medical expense is based, when the services are rendered within the service area. When emergency services are rendered outside the service area, this Plan pays based on usual, customary and reasonable charges of the area where services were rendered or according to the Blue Cross Blue Shield local Plan’s fees. When we precertify services that you receive outside the service area, we will pay for covered services according to: 1) the usual, customary and reasonable charges of the area where services were rendered; 2) the Blue Cross Blue Shield local Plan’s fees; or 3) Triple-S Salud’s established fees. The written precertification that we provide to you and the provider will indicate the allowance we will use. When you receive covered services outside the service area that are neither emergency nor precertified, we will reimburse 90% of Triple-S Salud’s established fees, after any applicable copay or coinsurance. You are responsible up to the billed charges for these services.
For services received by an employee (not available for dependents) due to Temporary Duty Assignment (TDY), Triple-S Salud will pay based on usual, customary, and reasonable charges of the area where the services were rendered in the United States. This benefit is not available overseas. The Agency must provide an official letter notifying Triple-S Salud, Inc. of the assignment. Services will be covered for a period of up to a maximum of three months.
For services received by a dependent that is a full-time student in a recognized educational institution in the United States, Triple-S Salud, Inc. will pay based on usual, customary and reasonable charges of the area where the services were rendered. The dependent must present a certification from the recognized educational institution as proof of study. This is required to determine eligibility of full-time student and must have the following specifications: The document must have the official stamp of the institution and it must indicate the total credits as well as the start and end date of the period of classes. (For associates or bachelor’s degree we consider 12 credits or more and for master's degree or graduate studies, 6 credits or more). Members must send us the updated evidence for each semester, quarter, or trimester, as applicable. The same benefit will apply to students entering TCC due to his/her age while they are full time students. Please send this request including your name and ID number directly to: servicioalcliente@ssspr.com
We have Open Access benefits
Our HMO offers Open Access benefits within our service area. This means you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.
We have Point-of-Service (POS) benefits
Our HMO offers POS benefits. This means you can receive covered services from a non-plan provider (out-of-network). However, out-of-network benefits have higher out-of-pocket-costs than our in-network benefits. When you receive out-of-network services, we pay 90% of the established fee for allowable charges. You are responsible for paying the non-plan provider up front for covered services and filing a claim for reimbursement. We will reimburse you directly for covered services unless the provider accepts assignment of benefits. You are responsible for all charges that exceed our payment. You may submit your reimbursement starting the date of service and you will have until December 31st of the consecutive year as the deadline to submit it. Example: If the services are received during 2024, you will have until 12/31/2025 to submit the reimbursement to us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). When you get services out-of-network, we reimburse members in Puerto Rico and in the U.S. Virgin Islands based on the “medical benefits schedule” and the member is responsible up to the billed charges for these services. When emergency services are rendered outside the service area, this Plan pays based on usual, customary and reasonable charges of the area where services were rendered or according to the Blue Cross Blue Shield local Plan’s fees. When we precertify services that you receive outside the service area, we will pay for covered services according to: 1) the usual, customary and reasonable charges of the area where services were rendered; 2) the Blue Cross Blue Shield local Plan’s fees; or 3) Triple-S Salud’s established fees. The written precertification that we provide to you and the provider will indicate the allowance we will use. When you receive covered services outside the service area that are neither emergency nor precertified, we will reimburse 90% of Triple-S Salud’s established fees, after any applicable copay or coinsurance. You are responsible up to the billed charges for these services.
Your rights and responsibilities
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Triple-S Salud, Inc. was organized by a group of physicians and dentists in 1959 and has been a health insurance option for Federal employees and annuitants since 1962.
- Triple-S Salud, Inc. is an independent licensee of the Blue Cross Blue Shield Association (BCBS). Triple-S Management Corporation is a publicly traded company on the New York Stock Exchange under the symbol GTS.
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, Triple-S Salud, Inc. at www.ssspr.com. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 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 P.O. Box 363628, San Juan, Puerto Rico, 00936-3628. You may also visit our website Triple-S Salud, Inc. at www.ssspr.com.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website Triple-S Salud, Inc. at www.ssspr.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Service Area
To enroll in this Plan, you and your dependents must live in our Service Area. This is where our providers practice. Our service area is limited to: Puerto Rico and U.S. Virgin Islands.
If you or a covered family member move outside of our service area, you can enroll in another Plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service Plan or an HMO that has agreements with affiliates in other areas. This Plan offers reciprocity with the Blue Cross Blue Shield network through the Blue Card Program subject to the terms and conditions of this plan. If you or a family member move, you do not have to wait until Open Season to change Plans. Contact your employing or retirement office.