Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Puerto Rico (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes			Primary care physician referral required	All-inclusive per diem or capitated payment	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes			Primary care physician referral required	All-inclusive per diem in private facility, capitated payment in public facility	CN & MN
Federally Qualified Health Center Services
Yes				Capitated payment	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes		Specified services		All-inclusive per diem	CN & MN
Outpatient Hospital Services
Yes			Elective surgery requires primary care physician referral	Fee for service with capitated payment for primary care	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes			Limited to services rendered by contracted staff	Fee for service or capitated payment	CN & MN
Rural Health Clinic Services
Yes				Capitated payment	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
No
Dental Services
Yes			1 exam and cleaning/year, frequency of x-rays limited by type	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes				Fee for service	CN & MN
Nurse Midwife Services
No
Nurse Practitioner Services
Yes				Fee for service for contracted staff	CN & MN
Optometrist Services
Yes			Limited to exams and evaluations	Fee for service for contracted staff, cost based payment for public health staff	CN & MN
Physician Services
Yes			Specialist care requires primary care physician referral	Fee for service with capitated payment for primary care	CN & MN
Podiatrist Services
Yes				Fee for service	CN & MN
Psychologist Services
Yes			Limited to services rendered by contracted staff	Fee for service or capitated payment	CN & MN
Prescription Drugs
Prescription Drugs
Yes		Specified high cost drugs and drugs not in plan formulary	Maintenance drugs limited to 30 day supply	AWP minus agreed upon discount and dispensing fees	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes				Fee for service for contracted staff, cost based payment for public health staff	CN & MN
Physical Therapy Services
Yes			Physician order required and limited to 15 treatments/condition/year	Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
Yes				Fee for service for contracted staff	CN & MN
Products and Devices
Dentures
No
Eyeglasses
No
Hearing Aids
No
Medical Equipment and Supplies
No
Prosthetic and Orthotic Devices
Yes		Yes		Negotiated fee	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service for contracted staff	CN & MN
Non-Emergency Medical Transportation Services
No
Other Services
Diagnostic, Screening and Preventive Services
Yes				Capitated payment	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes			Primary care physician referral required	Fee for service	CN & MN
Targeted Case Management
Yes			Limited to services rendered by health plan staff	Capitated payment	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
No
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
No - see territory-specific FN
Hospice Care
No - see territory-specific FN
Personal Care Services
No
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
No
Inpatient Psychiatric Services, under age 21
Yes	Specified services	All-inclusive per diem or capitated payment	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
No
Nursing Facility Services, other than in an Institution for Mental Diseases
No - see territory-specific FN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: The Commonwealth of Puerto Rico Department of Health, as the single state agency, manages the Medicaid program through an interagency cooperative agreement (contract) with the Puerto Rico Health Insurance Administration (PRHIA), a public corporation. The PRHIA negotiates and contracts with insurers and providers for comprehensive healthcare coverage for the Medicaid population. This structure operates in accordance with existing Medicaid law and managed care regulations. Like the other territories, Puerto Rico has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. The Deficit Reduction Act of 2005 provided additional funds to Puerto Rico, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceilings for 2008 and subsequent years will be calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The Commonwealth provides but does not claim federal Medicaid matching dollars for some of the services it provides. Accordingly, although some services are not indicated as a covered benefit on the tables because they are not included in the State Plan, such as Home Health Services, Hospice Care, Medical Equipment and Supplies and Nursing Facility Services, the Puerto Rico Health Insurance Administration makes the services available to Medicaid beneficiaries on an exception basis.