Catastrophic Remediable Illness Fund: help when the plan does not cover

It is a public fund of last resort for life-saving treatments. The law structures it in three pieces: the **Fund**, a special Health Department account; the **Evaluating Board**, which administers it and decides cases; and an **Executive Director** designated by the Board on the Secretary of Health’s recommendation. The Fund is **permanent and revolving**: any surplus at the close of each fiscal year stays in it for capitalization and to handle future cases. It is fed by legislative appropriations, by recovery of principal and interest on the loans it grants, and by donations; the Board is authorized to solicit and accept donations and to arrange time and space with the media to seek them. The law caps its operating expenses at a maximum of **three (3) percent** of the funds coming in, except salaries, which the Health Department pays, and **prohibits using the Fund’s money for purposes other than this Act’s**.

Article 5 asks five things at once. **(a)** Suffering a catastrophic illness whose foreseeable effect is loss of life. **(b)** That your physician certify they are aware of the condition and that medical science has successfully evidenced there is treatment remedying it to the point of saving the life. **(c)** That such treatment, including its diagnosis, **is not covered or is only partly covered** by the health insurance plans available in the general market, including the Government Health Plan. **(d)** That the patient, their family nucleus members or those legally obligated to support them **lack the economic means** to cover the costs and the means to obtain financing from private banking. **(e)** Having been **domiciled in Puerto Rico for at least two (2) years before applying**; if the patient is under two, the time their parents or legal guardians have resided in Puerto Rico is taken into account, and the law **expressly excepts** those who, for the sole purpose of receiving medical treatment, resided temporarily outside Puerto Rico and need to move back to receive it without having the means. To that is added **(f)**: accepting and complying with the terms and conditions the Board requires and releasing it, its members and the Commonwealth from any liability for the results of the treatment or diagnosis. The law defines "family nucleus" as the people living with the patient under the same roof or claiming them as a dependent on the tax return.

• Your physician’s certification that they are aware of the condition and that medical science has successfully evidenced there is treatment remedying it to the point of saving the patient’s life.Verified against the official source
• That the treatment, including its diagnosis, is not covered or is only partly covered by the health insurance plans available in the general market, including the Government Health Plan.Verified against the official source
• Having been domiciled in Puerto Rico for at least two (2) years before applying, with the two carve-outs the law writes: patients under two count their parents’ or guardians’ residence time, and those who resided temporarily outside solely to receive medical treatment are excepted.Verified against the official source

• The medical record the patient provides, which is what the Board evaluates. The Board **may require, if it deems it necessary**: copies of the last five (5) income tax returns; a credit report from an institution providing that service; evidence of debts, obligations and expenses; and any other document necessary to determine eligibility. The law says "may", not "must": these are not documents demanded of everyone up front.

1. 1

   Step 1: What a "catastrophic remediable illness" is

   The Article 3 definition has two branches and both are worth reading, because the second widens the Fund beyond the terminal. The **first** is the main one: an illness whose foreseeable effect, certified by a physician, is loss of life; for which medical science has successfully evidenced there is treatment remedying the condition to the point of saving the patient’s life, **or which, even if the treatment does not save the patient’s life, may relieve symptoms, help extend life expectancy or significantly improve quality of life, including prolonging the period during which the patient can care for themselves**; where that treatment is not covered or only partly covered; and where the means are lacking. The **second** branch covers illnesses that are **not terminal** but that **have caused a permanent impairment that could be seriously aggravated absent medical intervention** through treatment evidenced to remedy or prevent aggravation of the condition. For those cases the Board may authorize a grant, a loan or a combination, but with an express priority rule: **it may not authorize help in this type of case while help is pending for people whose condition falls in the first branch**. The definition **does not include epidemic diseases**.

2. 2

   Step 2: Supplementary expenses: transport, per diem and lodging

   It is the least known part and the one that most changes a family’s arithmetic. Article 10(j) empowers the Board to **authorize payment of supplementary expenses to the patients whose treatment is at issue and to their family members or guardians**, when in the Board’s judgment those expenses are necessary for the patient to receive the diagnosis and treatment. And it says what they may include: **the cost of transportation, per diem and lodging**. Note the law extends those expenses to family members or guardians, not only the patient, and that Article 4 confirms from the outset that the Fund is used to pay the costs of diagnosis and treatment **including supplementary expenses**.

3. 3

   Step 3: How the case is evaluated

   Article 10 gives the Board its concrete functions: **to receive and consider promptly** the applications; **to evaluate the patient’s medical condition according to the medical record the patient provides** and, if it deems it necessary, to require a second opinion or advice from a specialist or subspecialist. When the Board requires that expert opinion, it has **the free cooperation** of specialist physicians from the Colegio de Médicos Cirujanos, which will assign the specialist, who **must conclude their study of the case within the ten (10) days following the initial request** — a term extendable if the assigned physician deems it prudent — and **any analysis, test or study that physician requires shall be paid by the Board charged to the Fund**. The law adds a professional safeguard: **under no circumstance shall it be understood that in evaluating the patient’s medical condition, the Board’s physicians or those assigned by the Colegio are evaluating the competence of the physician who signed the record in the first instance**. On the financial side, the Board evaluates the socioeconomic and financial condition of the patient and their family nucleus, and **the Economic Development Bank is obligated to provide support when required, processing any such request in a term of less than ten (10) working days**. The Board also keeps a registry of recognized institutions in and outside Puerto Rico performing these treatments, and **negotiates the cost with them in order to lower it**.

4. 4

   Step 4: Your financial information cannot be used against you

   Article 11(a) is the guarantee that makes applying without fear possible, and it is worth quoting in full: **the financial information provided by every person interested in receiving assistance from the Fund shall be confidential and shall be used only for the purpose of determining the patient’s eligibility. Under no circumstance may the Board use that information to file any type of accusation or complaint against the person interested in receiving assistance from the Fund.** It is an uncommon rule and it is written without exceptions. The documents the Board may require — up to five years of tax returns, a credit report, evidence of debts and expenses — are covered by it.

5. 5

   Step 5: Grant, loan, or both

   Article 11(b) describes what the Board does when the application meets the medical and financial requirements: it confirms that the hospital institution your physician recommended, in or outside Puerto Rico, **is recognized by the Board** — and if it is not in its registry, the Board may recognize it or authorize treatment at one already recognized; it determines the allocation according to the cost of diagnosis and treatment, including supplementary expenses; it verifies the lack of means; and it authorizes, charged to the Fund, **whether by grant, loan, or a combination of both**, the full amount needed. If full assistance **as a grant** is warranted, subsection (c) orders authorizing payment of the diagnosis and treatment with such supplementary expenses as it deems proper and **authorizing the disbursement immediately**. If the patient or their family nucleus can pay **partly**, subsection (d) orders authorizing disbursement of the remaining amount, also as a grant, loan or combination. If the Board determines you are not eligible, **it shall promptly notify** the patient or their guardians. And the article closes with a sentence worth knowing: **under no circumstance, except a lack of resources in the Fund, shall attention to any eligible case be delayed while waiting for the patient, their guardians or family to obtain any private donation**.

6. 6

   Step 6: If it is a loan: half the interest and a year of grace

   Article 13 sets the terms and they are far gentler than a bank’s. **(a)** The loan shall be **at an interest rate equal to half the prevailing market interest, as certified by the Commissioner of Financial Institutions**. **(b)** The patient **shall begin paying the monthly installments one year after the treatment, regardless of its outcome**; and — this is the crucial part — **if the person responsible for repaying the loan is the patient and they become incapacitated, they will not have to pay it**. **(c)** Payments are made monthly, and the Secretary of the Treasury is authorized to arrange the corresponding monthly payroll deduction. In setting the payment plan, the Board **must do so taking into account that it not dramatically affect the debtor’s economic capacity** to continue with their obligations and with those the patient’s recovery or maintenance will entail. **Payment plans may extend from one year to fifteen (15) years**, none **shall take effect until at least twelve (12) months after the treatment**, and the Board, after a socioeconomic study, **may at any time re-evaluate the payment amount or cancel the outstanding balance**. Subsection (d) further allows an alternative plan: paying monthly or annually **a set percentage of net income** for a number of years not exceeding fifteen.

7. 7

   Step 7: Two limits worth knowing beforehand

   They must be stated because they change expectations. The first, Article 15: **nothing in this Act authorizes damages actions against the State or its officials or employees, against the Health Department or its officials or employees, or against the Evaluating Board and its officials or employees, for their actions, decisions or the results of the diagnosis and treatment performed on the patient**. It is consistent with eligibility requirement (f), which asks for releasing the Board, its members and the State from liability. The second, Article 17(b): **the Evaluating Board is excluded from the application of the Uniform Administrative Procedure Act** — the law cites Act 170 of 1988 and OGP notes it was repealed and replaced by Act 38-2017. That matters because the procedure and review the LPAU gives other administrative processes **do not apply here**, and the law creates no appeal procedure of its own. Article 12 does impose a rule of treatment: **the Health Department and the Evaluating Board or their officials or employees may not establish, in granting the benefits authorized by this Act, any discrimination on grounds of race, color, sex, birth, origin or social condition, or political or religious ideas**.

8. 8

   Step 8: How the Fund is sustained, and how you can contribute

   Article 16 opens two donation routes and one of them is surprisingly small and accessible. Contributions from corporations and partnerships to the Fund **shall be deductible** as provided for Charitable Donations in the Internal Revenue Code — the law cites the 1994 Code and OGP notes it was repealed and replaced by Act 1-2011. And it adds: **every individual may voluntarily contribute a minimum monthly amount of one dollar ($1.00) to the Fund**, through direct payroll deduction, whether a public or private employee, or **by sending a check payable to "Fondo: Ley Núm. 150 de 1996"**, and that contribution **shall be deductible on the tax return for the taxable year for which it was made**, if claimed in the space provided on the return. Article 14 completes the revolving design: the remainder the Board has not used or obligated at the close of each fiscal year stays in the Fund, and the balance of the special Treasury account is transferred annually to the Fund. Article 17(a) subjects the Fund’s assets, accounts, disbursements, funds and income to audit and oversight by the **Office of the Comptroller**.

Before the Evaluating Board of the Fund for Services against Catastrophic Remediable Illnesses, attached to the Health Department. Article 11(a) says **every interested person must file their application with the Evaluating Board**, under the Article 5 requirements. It is administered by an Executive Director designated by the Board on the Secretary of Health’s recommendation, according to the rules and regulations the Board establishes, and those regulations require the Secretary of Health’s approval. What we do not publish: the application form, address, phone, portal, the Board’s regulation, the current interest rate — the law defines it as half the prevailing market rate as certified by the Commissioner of Financial Institutions, a figure that changes — or a determination deadline. The law orders the Board to **receive and consider promptly** the applications and to **promptly notify** ineligibility, but sets no days. That is why cost and processing time stay unverified.

• Ruling yourself out for having the Government Health Plan: the law expressly covers treatment that plan does not cover or covers only partly.
• Not requesting supplementary expenses: the Board may authorize transportation, per diem and lodging, and not only for the patient but for family members or guardians.
• Believing it applies only to terminal illnesses: the definition’s second branch covers non-terminal conditions with permanent impairment that could be seriously aggravated.
• Assuming that if the treatment does not save the life it does not qualify: the definition includes relieving symptoms, extending life expectancy or significantly improving quality of life.
• Overlooking the two-year domicile requirement, or not knowing the exception for someone who lived outside solely to receive medical treatment.
• Not filing the medical certification with the content the law asks for: that the physician is aware of the condition and that there is evidenced treatment.
• Fearing to hand over financial information: the law makes it confidential and prohibits using it to file an accusation or complaint against the applicant.
• Waiting to secure a private donation: except for a lack of resources in the Fund, no eligible case is delayed by that wait.
• Taking for granted there is an LPAU appeal: the Board is excluded from that law.

These are the government pages this guide is based on.

• Departamento de Salud de Puerto Rico

  Salud

  bvirtualogp.pr.gov

• Puerto Rico Department of Health

  Salud

  www.salud.pr.gov