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Medicare Advantage News

Some See Puerto Rico As Separate Region; Link With Florida Rejected

October 1, 2004
Copyright © 2004 Atlantic Information Services, Inc. All rights reserved. 

Groups representing Puerto Rico's hospitals, health care insurers and executives, along with the island's public health officials, concur in their comments recently submitted to CMS on how to configure regions for Medicare Advantage (MA) PPOs and Prescription Drug Plans (PDPs) in 2006. All are urging the federal government to designate Puerto Rico as a separate, stand-alone region for regional Medicare plans, contrary to the four multistate options outlined at a July 21 CMS public meeting (MAN 8/04, p. 1).

Socorro Rivas, president and CEO of Triple-S, Inc., a Medicare Part B carrier and Blue Cross and Blue Shield Association licensee based in San Juan, is asking CMS to "protect" the island's elderly by designating a separate MA region for Puerto Rico. He notes that Puerto Rican beneficiaries would account for only 15% of the beneficiary total if Puerto Rico were to become part of a region with Florida. Puerto Rico has had one MA plan since 2001 and got a second one, Preferred Medicare Choice, Inc., this summer (MAN 9/04, p. 6).

In an Aug. 25 letter to CMS, Rivas asserts that Puerto Rico qualifies as a stand-alone region because its 601,773 Medicare eligibles place it above many states with fewer eligibles, including Connecticut, Arkansas, Colorado, and Kansas.

He also cites cultural and economic considerations, including less education and more poverty, in Puerto Rico as compared to Florida. For example, he says 58% of Puerto Ricans aged 65 and over have less than a ninth grade education vs. 12% of Florida's seniors, and he says 20% of Puerto Rico's Medicare beneficiaries lack a phone.

Another supporter of a stand-alone region is Enrique Baquero-Navarro, regent for Puerto Rico for the American College of Healthcare Executives. In an Aug. 4 letter to CMS, he notes that geographic access in Puerto Rico is defined as 30 minutes or 39 miles from home, a higher standard than in the mainland U.S. And he says Puerto Rican beneficiaries need culturally and linguistically appropriate services. If Puerto Rico is put in a state-based PPO region, he says, MCOs based in Puerto Rico would be "clearly disadvantaged" when competing with U.S. MCOs to build provider networks outside the island.

Florida and Puerto Rico Termed Disparate

In an Aug. 5 letter to CMS, Johnny Rullan, M.D., of the Puerto Rico Dept. of Health asserts that the HHS Secretary is authorized specifically to create MA regions for U.S. territories, and that these territories, including Puerto Rico, are not subject to the 50-region statutory ceiling.

Rullan notes Puerto Rico was combined with Florida in each of the multistate region options presented at CMS's July meeting, Yet while Florida is geographically closest to Puerto Rico, he describes Florida and Puerto Rico as disparate in terms of economy, health care systems and infrastructure, and patient demographics.

For example, Rullan notes that Florida's cost structure is significantly higher than that of Puerto Rico, with estimated MA payment rates of $712.52 vs. $507.09, respectively. Also, Florida's average health status is lower, he says, so when estimated payment rates are adjusted for health status, Florida's rate rises by nearly $65 a month while Puerto Rico's monthly rate increases by a mere 70 cents. As a result, plans that bid on serving all Medicare eligibles in a region that includes Florida and Puerto Rico will have to submit a bid with premiums and copays large enough to support the higher costs of doing business in Florida, he says, with the likely result that plans will be too costly for most Puerto Rican seniors. New York has a higher cost structure and less healthy population than Puerto Rico, he says, so that combination likely would create the same problems.

Yet a physicians' group is urging CMS to put Puerto Rico in the New York region. In an Aug. 9 letter to CMS, Marissel Velazquez Vicente, president of the Physicians and Surgeons College of Puerto Rico, states that the group opposes transfer of Puerto Rico to the Florida region, and opposes creation of a stand-alone region for Puerto Rico because it will further "isolate" the island and result in "greater discrimination." Velazquez Vicente cites already lower Medicare payment rates for physicians in Puerto Rico than in any other state or territory, and lack of Supplemental Security Income (SSI) benefits in Puerto Rico, and asserts that the best alternative is to stay in the New York region, which has the highest concentration of Puerto Rican citizens.

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