Ultimate Guide to Puerto Rico Medicaid

Unlike any other U.S. state or territory, about half of Puerto Rico residents are eligible for Medicaid. However, Medicaid is a bit different in Puerto Rico. If you’re familiar with traditional U.S. state Medicaid, you may be confused.

This guide will explain how Medicaid in Puerto Rico is different, what it covers, and how to enroll.

Does Puerto Rico Get Medicaid?

All 50 states and all U.S. territories (Puerto Rico, American Samoa, Guam, Northern Mariana Islands, U.S. Virgin Islands) have access to the United States Medicare and Medicaid programs, though it may be a little different in each place.

Here’s how Puerto Rico Medicaid is different from in U.S. states:

The Puerto Rico Department of Health coordinates with the Puerto Rico Health Insurance Administration (PHRIA) to administer the island-wide system. About half of Puerto Ricans have low incomes and depend on the public health system.
Each territory is provided specific Medicaid funding. In the 50 states, each state is responsible for dictating Medicaid budget.
In the states, rates are based on per capita income. In Puerto Rico, it is 57.2%.

Who is Eligible for Medicaid in Puerto Rico?

Puerto Rico Medicaid and CHIP (Children’s Health Insurance Program) eligibility is based on income. To qualify, you cannot make more than the following:

Medicaid, Household of 1 – $550/month
Medicaid, Household of 2 – $650/month
Medicaid, Household of 3 – $750/month
Medicaid, Household of 4 – $850/month

$100 per additional household member

CHIP, Household of 1 – $1,100/month
CHIP, Household of 2 – $1,300/month
CHIP, Household of 3 – $1,500/month
CHIP, Household of 4 – $1,700/month

$200 per additional household member

What Does Puerto Rico Medicaid Cover?

Puerto Rico’s Medicaid program operates under a “Managed Care” plan. There are two managed care pans: Mi Salud, and Medicare Platino. The Medicare Platino program is only for people who are eligible for both Medicaid AND Medicare in Puerto Rico, which means those who are only eligible for Medicaid and not Medicare can only enroll in the Mi Salud program.

Mi Salud is operated by “Triple S,” a San Juan-based insurance company, and includes:

Inpatient and outpatient hospital care
Primary care
Prescriptions
Dental
Transportation

Though only one carrier (Triple S) participates in Mi Salud, there are seven that participate in Medicare Platino: American Health Medicare/BCBS, First Medical/First Plus, Humana, MCS, MMM Healthcare Inc., PMC Medicare Choice, and Triple S.

Medicare Platino covers everything that Mi Salud covers but adds inpatient and outpatient behavioral health services.

Can you Get Both Medicare and Medicaid in Puerto Rico?

You absolutely can have both Medicare and Medicaid in Puerto Rico! To be eligible, you’ll have to meet the income requirements for PR Medicaid, but also qualify for Medicare by either:

Being at least 65 years old
Receiving SSDI (Social Security Disability Income) for at least 25 months
Being diagnosed with ALS or ESRD

You can enroll in Medicare by visiting Medicare.gov or going to your local Social Security office. Once you’ve applied for both Medicare and Medicaid, you can get Medicare Platino.