Puerto Rico Medicaid Overview

“The Medicaid program in Puerto Rico differs from Medicaid programs operating in each of the 50 states and the District of Columbia in three important ways.

• The Puerto Rico Medicaid delivery system is a subset of the larger public government healthcare delivery system for most of the island’s population. The Puerto Rico Department of Health is the single state agency, and they have a cooperative agreement with the Puerto Rico Health Insurance Administration (PRHIA) also known as Administracion de Seguros Salud de Puerto Rico (ASES) which implements and administers island-wide health insurance system. Approximately half of Puerto Rico’s 3.5 million residents have low incomes and depend upon the public health system for their medical care.
• Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $5.4 billion in Medicaid funding to Puerto Rico.
• Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in Puerto Rico, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing Puerto Rico’s FMAP to 57.2%.”