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Puerto Rico Medicaid Coverage.



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:

  1. 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. 
  2. Each territory is provided specific Medicaid funding. In the 50 states, each state is responsible for dictating Medicaid budget.
  3. 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

Medicare Games

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.

How to Get Medicaid in Puerto Rico

To apply for Medicaid in Puerto Rico, first click here to find out if you are eligible.

To download the Puerto Rico Medicaid application, click here.

It is recommended that you make an appointment with your local office to get help completing your application.

Puerto Rico Social Security Offices

Aquadilla

Borinquen Town Plaza

Aquadilla, PR 00603

 

Arecibo 

880 Isaac Cruzstgo St.

Arecibo, PR 00612

 

Bayamon

Road 167 Forest Hills Plz 2fl

Bayamon, PR 00959

 

Caguas

30 Padial St.

Caguas, PR 00725

 

Carolina

5829 65 Infanteria Ave

Carolina, PR 00987

 

Fajardo

102 Garrido Morales

Fajardo, PR 00738

 

Guayama

54 Rd 3 Albizu Campos

Guayama, PR 00784

 

Humacao

75 J Aguiar Aramburu

Humacao, PR 00791

 

Manati

Esq  Expreso To Ciales

Manati, PR 00674

 

Mayaguez

357 Hostos Ave

Mayaguez, PR 00680

 

Ponce

2190 Ponce By-pass

Ponce, PR 00716

San Juan

1579 Ave Ponce De Leon

San Juan, PR 00926

Turning 65 and Medicare

Have questions? Call a Licensed Agent!