How to apply for Plan Vital (Medicaid) in Puerto Rico

Plan Vital is Puerto Rico’s government health plan. ASES, the Health Insurance Administration, is the agency that runs it: it defines the coverage, contracts the insurers and organizes service by region. What confuses almost everyone is that ASES is not who decides whether you qualify. That decision is made by Puerto Rico’s Medicaid Program, a separate office with its own process and its own site at medicaid.pr.gov. In practice the process has two parts: first Medicaid determines your eligibility, and then, if you are eligible, you are assigned Plan Vital coverage and you choose your insurer and medical group. Many people lose weeks calling ASES about an application that actually sits with Medicaid, or the other way around.

Eligibility is determined by Puerto Rico’s Medicaid Program, which evaluates the whole household. The factors generally considered include household composition, household income and resources, residency in Puerto Rico, age, pregnancy or a disability or medical condition, and each member’s immigration status under the categories the program recognizes. PRFácil does not publish income limits or household-size thresholds, because those figures change and a wrong figure here could leave someone without health coverage because they believed they did not qualify. Two things worth knowing: the program evaluates each household member separately, so it is common for children to qualify even when the adults do not; and losing a job, having a baby or a change in your household are the kinds of changes that can make you eligible when you were not before. If you are unsure, apply and let Medicaid determine your case.

• Reside in Puerto Rico.
• Have Puerto Rico’s Medicaid Program determine your eligibility before you receive Plan Vital coverage.
• Present information for the entire household, not just yourself.
• Be able to document the household’s income and resources, or explain why there is no income.
• Identify each household member’s immigration status under the categories the program recognizes.
• Recertify and report household changes when the program requires it, so you don’t lose coverage.

• Current photo identification for the applicant.
• Birth certificate or proof of identity for each household member you are including.
• Proof of household income, such as pay stubs, benefit letters or other documentation the program accepts.
• Proof of Puerto Rico residency, such as a utility bill or a lease.
• Immigration status documents for non-citizen members, where applicable.

1. 1

   Step 1: Start with Medicaid, not with ASES

   This is the step people skip. ASES runs Plan Vital, but the one that decides whether you qualify is Puerto Rico’s Medicaid Program, on its own site. If you start by calling ASES or an insurer, they will most likely send you back to Medicaid. Go straight to the right source and save yourself the trip.

2. 2

   Step 2: Gather documents for the whole household

   The evaluation covers the household, so you will need identity and income for each person you include, plus proof of residence. If someone in the household is missing a birth certificate, start requesting it now: that separate errand is the most common reason a Medicaid application sits waiting.

3. 3

   Step 3: File the Medicaid eligibility application

   Complete the application with your household’s real information, including small or irregular income. The Medicaid Program maintains service offices; the official site is what carries the current list and the available ways to file. Write down any case or confirmation number they give you and keep it.

4. 4

   Step 4: Respond to interviews and document requests

   It is normal to be asked for additional documents or to be called in. Respond within the deadline they give you and keep dated proof of what you submitted. Most applications that get stuck are not denied: they are waiting on something nobody explained clearly to the applicant.

5. 5

   Step 5: If you are found eligible, choose your insurer and medical group

   Plan Vital is delivered through insurers contracted by ASES, organized by region. Once you are eligible you get to choose — or are assigned — an insurer and a primary medical group. Before deciding, check that your usual doctor or clinic is in the network of the option you pick, because changing later is more of a hassle.

6. 6

   Step 6: Recertify before your coverage lapses

   Medicaid eligibility is not permanent: you must recertify when the program tells you to and report changes in your household or income. Losing coverage by not recertifying on time is common and avoidable. Keep the letters you receive and don’t leave them unopened.

Eligibility is applied for with Puerto Rico’s Medicaid Program, which maintains its own official site and service offices. Information about Plan Vital coverage, contracted insurers and regions is published by ASES on its site. Check both official sites for current addresses, hours and filing methods; PRFácil does not publish addresses or hours it has not verified.

• Starting with ASES or an insurer when eligibility is determined by Puerto Rico’s Medicaid Program.
• Assuming nobody in the house qualifies because the adults don’t, when each household member is evaluated separately.
• Not reporting a significant change — job loss, a birth, someone moving in or out — that is precisely what could change eligibility.
• Letting recertification lapse and losing health coverage even though the family is still eligible.
• Choosing an insurer or medical group without checking whether your usual doctor or clinic is in that network.

These are the government pages this guide is based on.

• Administración de Seguros de Salud (ASES)

  ASES

  www.ases.pr.gov

• Puerto Rico Medicaid Program

  Medicaid PR

  www.medicaid.pr.gov

• ASES — official site

  ASES

  www.ases.pr.gov