Cancer coverage: the plan’s 72 hours and the automatic yes

These are two short laws read together. Act 79-2020 sets what must be covered and how fast they must answer; Act 107-2012 keeps the route by which chemotherapy is administered from deciding whether it is covered. Act 79-2020 sits above the insurance codes: where it conflicts with the Puerto Rico Insurance Code or the Health Insurance Code, it prevails. And it applies without exclusion to all insurers, third parties they contract, administrators, benefit managers and those contracting with ASES — meaning it also reaches the Government Health Plan.

Every covered or insured person under an individual or group health plan in Puerto Rico who is in the process of cancer diagnosis or treatment. The law defines cancer diagnosis early: it is the process of identifying and assessing a finding, once a lump or another sign or symptom has been found, using the diagnostic tests contained in the NCCN guidelines. That is, the deadlines do not start once cancer is confirmed, but from the tests that seek to confirm it. An honest limit: the law applies prospectively and does not impair contractual obligations predating it; contracts signed earlier had to comply upon expiration, extension or renewal.

• That the medication, treatment or diagnostic test be in the National Comprehensive Cancer Network (NCCN) guidelines or approved by the FDA.Verified against the official source
• That the plan has received a request: the 24 to 72 hour terms run from receipt of the request.Verified against the official source
• For designating the oncologist as primary care provider, that the health professional consents to the designation.Verified against the official source

• The authorization request your physician or oncologist submits to the plan, with a receipt date. The date is what makes the term measurable.
• The specialist’s or oncologist’s medical order when the claim is about the chemotherapy administration method, because Act 107-2012 ties coverage to that order.

1. 1

   Step 1: Mark the case urgent if it is

   The general term is 24 to 72 hours from receipt of the request, but drops to 24 hours when the case is marked urgent or expedited. Whoever submits the request marks it, so it is worth discussing with your physician or oncologist before they send it, not after the clock starts.

2. 2

   Step 2: Write down the date and time the plan received the request

   The whole article depends on that moment: the term runs from receipt of the request. Ask the medical office for the acknowledgment of receipt, the reference number or the confirmed fax. Without that date you cannot claim the term expired or that it was automatically approved.

3. 3

   Step 3: If the term expires, claim the automatic approval

   Article 6 says it without conditions: if the plan fails to issue its determination within that term, the medications, treatments and/or diagnostic tests shall be deemed approved by it. It is not that you get a better appeal; it is that the law deems approved what the plan left unanswered. Put it in writing to the plan, with the request’s receipt date and the article citation.

4. 4

   Step 4: If the problem is the administration route, cite Act 107-2012

   A health benefit plan that provides coverage for cancer chemotherapy treatment must equally provide coverage of chemotherapy in its various administration methods: intravenous, oral, injectable or intrathecal, per the medical order of the specialist physician or oncologist. It applies to insurers and health service organizations, to plans serving Puerto Rico, to any entity contracted to offer health benefits, and to ASES and whoever contracts with it.

5. 5

   Step 5: Ask that your oncologist be your primary care provider

   If your plan requires you to designate a primary care provider, Article 7 allows a physician specialized in oncology to be designated in that capacity for cancer patients, as long as that health professional gives consent. The law says the plan may allow it, so start by asking the plan in writing and by confirming the oncologist’s consent.

6. 6

   Step 6: Take the non-compliance to the Patient Advocate

   The Office of the Patient Advocate has jurisdiction to intervene in violations of patients’ rights under this law, and may issue a non-compliance report. That report is referred to the Office of the Insurance Commissioner and is sufficient basis for it to start and complete an adjudicative process against the insurer. It may also be referred to ASES, where it is sufficient basis to begin cancelling the insurer’s Government Health Plan contract.

The authorization request is submitted by your physician or oncologist to your health plan or to whoever administers your benefits. The non-compliance claim goes to the Office of the Patient Advocate, which has express jurisdiction under this law. The Office of the Insurance Commissioner is the one that sanctions the insurer, and the law ordered it to amend its regulation to include non-compliance with this law as grounds for license suspension or revocation. If you are on the Government Health Plan, ASES is the third route: a non-compliance report is sufficient basis to begin cancelling the insurer’s contract.

• Letting the term expire without claiming it: the law deems approved whatever the plan did not answer in 24 to 72 hours.
• Not asking for the request’s acknowledgment of receipt, which is where the term runs from.
• Not marking the case urgent or expedited when it is, which would have dropped the term to 24 hours.
• Believing the mandatory coverage only covers chemotherapy: it includes what is needed to treat and minimize its adverse effects.
• Accepting a denial of the oral version of a treatment the plan covers intravenously.
• Accepting a clause leaving final contract interpretation to the insurer’s discretion, which the law prohibits.
• Thinking the Government Health Plan is outside this: the law applies without exclusion to those contracting with ASES.

These are the government pages this guide is based on.

• Oficina del Procurador del Paciente (OPP)

  Procurador del Paciente

  bvirtualogp.pr.gov

• Act 107-2012 — equal coverage of oral and intravenous chemotherapy

  OGP

  bvirtualogp.pr.gov

• Act 275-2012 — Bill of Rights of Cancer Patients and Survivors

  OGP

  bvirtualogp.pr.gov

• File your claim — Patient Advocate

  OPP

  www.opp.pr.gov

• Office of the Insurance Commissioner

  OCS

  ocs.pr.gov