Prenatal, birth and postpartum care without health insurance

It is a Government of Puerto Rico health coverage, not a private plan or a federal program. Its statement of motives tells where it comes from: in 2012 an Executive Order directed the Secretary of Health to establish a mechanism to provide these services without regard to migratory status, and the Health Department approved a regulation to that end; the Legislature considered those services **should flow from a more robust legal source**, and so turned them into law. Article 4 amends Act 72-1993 on the Health Insurance Administration to add as Health Plan beneficiaries **pregnant and medically indigent women in Puerto Rico, without regard to their migratory status, in accordance with the availability of exclusively state funds assigned for those health services**. We mention the Executive Order and the regulation because the law names them; **we do not describe them, because the law does not reproduce them and we did not read them**.

Article 3 asks three things and no more. **(a) A pregnant woman**, which for this Act’s purposes refers to any female person holding results from a duly licensed clinical laboratory showing a positive pregnancy test. **(b) Domiciled in Puerto Rico.** **(c) Being medically indigent.** The Health Department establishes, by regulation, the information and documents applicants must present so the Government can confirm that domicile is Puerto Rico and that they lack the economic means to pay for private health insurance; **the law does not publish that document list and we do not invent it**. And it closes with the rule ordering the whole process: **the Health Department shall not consider the migratory status of medically indigent pregnant women when requiring, by regulation, information tied to the eligibility criteria**.

• Holding results from a duly licensed clinical laboratory showing a positive pregnancy test. That is the definition the law itself gives of "pregnant woman" for these purposes.Verified against the official source
• Being domiciled in Puerto Rico.Verified against the official source
• Being medically indigent. The law charges the Health Department with setting by regulation how it is confirmed that the applicant lacks the economic means to pay for private health insurance.Verified against the official source

• The licensed clinical laboratory results with the positive pregnancy test. The remaining documents — those proving domicile and medically indigent status — are set by the Health Department by regulation; **the law does not list them and we do not publish them**.

1. 1

   Step 1: Migratory status is not part of the equation

   The law says it twice and in two different registers, and both matter. In Article 2, as public policy: **preventing illness in pregnant women and newborns through adequate, accessible medical care is considered fundamental, without taking the applicant mother’s migratory status into consideration**. And in Article 3, as an operative rule addressed to the agency: **the Health Department shall not consider the migratory status of medically indigent pregnant women when requiring, by regulation, information tied to the eligibility criteria established by this Act**. The second governs the counter: it is not only that status does not disqualify, it is that the Department must not consider it when defining what information to request. The law says nothing about sharing information with other agencies, and **we assert nothing about that**.

2. 2

   Step 2: What it covers, service by service

   Article 5 orders the Health Department to establish the coverage’s minimum services, and previews a list saying **some of these medical services may be, without being limited to**: **(a)** initial office visit; **(b)** follow-up visits; **(c)** fetal monitoring; **(d)** one sonogram per trimester; **(e)** an amniotic fluid index calculation; **(f)** a non-stress test; **(g)** consultation for fetal evaluation; **(h)** emergency health service for pregnancy-related conditions during the prenatal period; **(i)** ground ambulance transportation in emergencies; **(j)** folic acid; **(k)** ferrous sulfate; **(l)** medication to treat diabetes and high blood pressure; **(m)** medication in tablet form, without limitation, such as antibiotics; **(n)** natural birth; **(o)** cesarean birth; and **(p)** medical services for complications during or after birth, **for a period of up to sixty (60) days**. The law adds that the Department **may amend the medical services for this health coverage, according to the sufficiency of available state funds**, so the list is a floor described by the law, subject to what the Department determines.

3. 3

   Step 3: Where the services are received

   Article 7 opens the door: **all pregnant women meeting this Act’s eligibility criteria may receive prenatal, birth and postpartum health services at the clinics established and agreed by the Puerto Rico Department of Health**. And it adds an obligation worth knowing: **it is established that every hospital or clinic belonging to a Municipality of Puerto Rico and to the Government of Puerto Rico, without being limited to the Centro Médico, and at the discretion of the Secretary of Health, shall be obligated to provide the medical services covered by this Act, at their facilities, for the purposes established in this Act**. Services for complications within the sixty-day period after birth **shall be covered according to clinical need as established by the Health Department by Regulation**. Everything relating to pharmacy services is determined by the Health Department, which **may coordinate with the municipalities**, and the Department **may enter contracts, agreements and exchanges with non-profit associations to administer the coverage**. **We do not publish the clinic list or addresses: the law does not name them.**

4. 4

   Step 4: Copays and deductibles: the law does not set them

   This must be said plainly because it is the most asked question. Article 6 provides that **the Puerto Rico Department of Health shall have authority to establish the copays and deductibles for the services this health coverage provides**, and adds that it **shall have the power and discretion to amend copays, coinsurance and deductibles at any time, according to the economic resources available for this health coverage and the experience of the services offered**. That is: the law acknowledges there may be copays and deductibles, but **sets no figure and allows them to change at any time**. That is why this guide’s cost stays unverified: publishing an amount would be inventing it.

5. 5

   Step 5: Where the money comes from, and why it matters

   Article 8 is clear: **the funds used to pay for this health coverage must come exclusively from state funds**. The Health Department may identify and allocate funds from its own budget to subsidize the costs, and may request that the Government assign it additional funds exclusively for this coverage. It may also enter agreements, contracts and exchanges with providers under current law, and the form of payment to providers — per member per month ("capitation"), fee for service, or any other method — shall be by mutual agreement, **with the Department able to modify rates according to available funds**. This matters because the law itself conditions the coverage’s reach on the availability of those funds: Article 4 says so when adding the beneficiaries "in accordance with the availability of exclusively state funds", and Article 5 when allowing services to be amended "according to the sufficiency of available state funds".

6. 6

   Step 6: The participant registry

   Article 9 orders that **the Puerto Rico Department of Health shall establish a Registry of all participants**. The law creates the registry and says no more: it does not describe what data it holds, who may access it, how long it is kept or with whom it is shared. **We do not fill that gap**, and we point it out precisely because, this being a coverage the law itself directs at women without regard to migratory status, it is reasonable for a reader to want to know before applying. The honest thing is to say this law does not answer it.

Before the Puerto Rico Department of Health, and services are received at the clinics established and agreed by the Department. Article 7 adds that every hospital or clinic belonging to a municipality and to the Government of Puerto Rico, without being limited to the Centro Médico and at the Secretary of Health’s discretion, is obligated to provide at its facilities the medical services covered by this Act. What we do not publish: the clinic list, addresses, phones, the application form, the eligibility documents — which Article 3 leaves to regulation — the copays and deductibles — which Article 6 leaves to the Department and lets it change at any time — or the determination deadline. That is why cost and processing time stay unverified.

• Believing a prior health plan is needed: the coverage exists precisely for medically indigent pregnant women.
• Not getting the lab test: the law defines "pregnant woman" as one holding duly licensed clinical laboratory results with a positive test.
• Not applying because of migratory status: the law orders the Department not to consider it when requiring eligibility information.
• Assuming coverage ends at birth: it includes services for complications during or after birth for a period of up to sixty (60) days.
• Not counting the sonogram per trimester or the non-stress test among what is covered: the law lists them expressly.
• Accepting rejection by a municipal or Government hospital: Article 7 imposes on them the obligation to provide the covered services.
• Expecting copay figures in the law: the Department sets them and may amend them at any time.
• Treating the service list as closed: the law says "without being limited to" and lets the Department amend it according to available state funds.

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