On Mar. 7, PR RICO INS issued changes to instructions and checklists.
PR RICO INS issued 2 Circulars: one is Circular letter CN-2025-368-ASon significant changes to the instructions and checklists for the submission of the ACA health plans.
Other id Circular letter CN-2025-367-AS to change the instructions and checklists.
Also, contains attachments re forms and rates requirements for 2026 metallic plans.
Attachments
Att. 1, Rate Filing Instruction Manual; Att. 2, Part I Unified Rate Review Template Instructions; Att. 3, Part III Actuarial Memorandum and Certification Instructions.
Att. 4, Benefits Map; Att. 5, Unified Tariff Review Template; Att. 6, Essential Health Benefits and Preventive Services Checklist; Att. 7A, Checklist for Individual Market.
Att. 7B, Checklist for Small Group Market; and Att. 8 Essential Health Benefits.
In accordance with Chapters 8 and 10 of the Health Insurance Code of Puerto Rico.
Disability Insurers and Health Insurance Organizations must submit each year all forms and rates re metallic plans, for review and approval, even without changes.
Requirements to file rates with PR RICO INS must be complied only by Health Maintenance Organizations (HMOs) writing health coverage and all rate changes.
The noncompliance of one or more requirements will result in the filling rejection.
Every health plan insurer and health services organization must comply with the law and requirements established by the Actuarial Analysis Division applicable to the law.
The review process of medical plans will not be stopped for pending queries matters.
Rates Submissions
Rate filings for non-grandfathered individual plans that will come into force on Jan. 1, 2026, must be submitted to PR RICO INS on or before May. 31, 2025, via SERFF.
Submission through the Systems for Electronic Rates and Forms Filings (SERFF).
Carriers must only use rates filed and approved by PR RICO INS, others not allowed.
All HMOs rate increases and all Disability insurers rate increases equal to or greater than 10% of rates one year prior must be submitted following the Instruction Manual.
Every SERFF filing must include the correct information, otherwise it will be rejected.
Forms Submissions
Forms filings for non-grandfathered individual plans must be submitted by May 31.
PR RICO INS will not guarantee the approval of the submitted forms before Oct. 1, 2025, if the carrier does not comply with the established submission deadline.
Annual metallic level plans are a new product and entails comprehensive evaluation.
Every filing must be submitted through SERFF and include all the information required.
Specified clarifications of certain benchmark requirements, state and federal laws.
Carriers must only use forms filed, approved by PR RICO NS, including drug formulary.
Insurers or health services organizations are not exempted from complying with the implementation of new benefits required by the state or federal law, issued later on.
Each metallic plan description of benefits and metallic level will be made public.
If a carrier offers health plan, it must renew or continue in force, as applicable.
Large Group Rates and Form Filings
These must not be submitted for the PR RICO INS evaluation and approval process.
Exemption will apply to health insurance organizations or issuers underwriting health insurance coverage in large group market, includes Healthcare Services Organizations.
Rate increases of 10% or more over the previous year's rates for large group health insurance coverage must be filed with PR RICO INS at least 90 days before in force.
Supplemental Health Care Exhibit (SHCE)
All carriers required to complete, submit the Supplemental Health Care Exhibit (SHCE).
Disability insurers must submit it before Mar. 30, HMOs must submit it before Mar. 31.
Include copy of exhibit as part of the requirements in Supporting Documentation Tab.
A failure to submit this exhibit will result in the filing's rejection without evaluation.
