In the meantime, the clock keeps on ticking and ASES has still to submit the contracts to the Centers for Medicare & Medicaid Services (CMS) for their approval, an essential step, as 55% of GHP comes from federal funds. (horizontal-x3)
In the meantime, the clock keeps on ticking and ASES has still to submit the contracts to the Centers for Medicare & Medicaid Services (CMS) for their approval, an essential step, as 55% of GHP comes from federal funds. (GFR Media)

Time is short but the contracts with insurers who will manage the Government Health Plan (GHP) during the next fiscal year (2017-2018) have not been signed, because the rates and other economic clauses are still being discussed.

“We continue to work on the negotiation process for the next fiscal year with the Health Insurance Administration (ASES, by its Spanish acronym). But, while the process is still open, it’s distinguished itself for being conducted in a collaborative manner so as to ensure the wellbeing of Puerto Rico’s Medicaid population,” reported First Medical Health Plan through Mayra Rivera, its marketing and communications.

In February, Ángela Ávila, director of ASES, said her wish to extend the GHP administration contracts to the five state entities on whom this role was delegated since April 2015 (Triple-S, MMM, PMC, First Medical, and Molina Healthcare).

These contracts would last two years, but include a clause to extend them for an additional year because the negotiations coincided with the end of an election year.

Following the endorsement by the ASES Board of Directors, the corporation went on to review the reasonability of premiums, an analysis that helps determine the existence of situations that may justify cost increases and whether premiums should be either maintained, increased or reduced. El Nuevo Día learned of at least, three rounds of negotiations that have taken place between representatives for the companies and ASES over this matter.

“We are fully immersed in a negotiation process. This is a collaborative effort, which goal is to obtain an agreement that is positive for all the parties and ensures access by beneficiaries to quality health services. On the other hand, as industry members, we have actively cooperated with the government to achieve the allocation of additional funds required by ASES for the Government Health Plan, ahead of the anticipated end to the moneys allocated to Puerto Rico under Obamacare,” said Dorelisse Juarbe, Senior Vice President Medicare Advantage and Triple S’ Government Health Plan.

The fiscal abyss, is the moment at which the Obamacare funds that have sustained the GHP run out, which dismays both the government and the health industry. This is expected to occur this year.

“We’re in constant communication with the ASES and trust that the process and the new contract will be completed in time for the new fiscal year,” said Myriam Aguilú, spokesperson for MMM and PMC (MMM Healthcare).

In the meantime, the clock keeps on ticking and ASES has still to submit the contracts to the Centers for Medicare & Medicaid Services (CMS) for their approval, an essential step, as 55% of GHP comes from federal funds.

Ávila had told this daily that the contracts had to be signed before June 18, and come into effect July 1.

This daily has learned that one of the stumbling blocks is that insurers are asking the government for guaranties that, once the Medicaid funds run out, there will be money to fund the Reform. This because, after the contracts are signed, the responsibility for making sure that services are provided to patients will fall on insurers who manage the GHP, regardless of whether payment is made.

“Molina Healthcare de Puerto Rico makes no comments on the negotiations for pending contracts,” Madeline Figueroa, the company’s Chief Operations Officer, would only say.

Once the contracts are signed, the government will have to work on Request for a Quote to choose the entity or entities that will administer the Reform during 2018-19, when the new health model is expected to become effective.


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