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Medicare Advantage in Puerto Rico

Jennifer González-Colón, together with ten other Members of Congress, wrote a letter to Xavier Becerra, Secretary of the U.S. Department of Health and Human Services, expressing concern over Medicare Advantage (MA) in Puerto Rico.

“[W]e are writing to request that you consider adopting the necessary policies to reduce the
current inequities in the operation of Puerto Rico’s MA program,” the letter began. “Doing so will dramatically improve health care services for 630,000 U.S. senior citizens living in Puerto Rico, including more than 280,000 dally eligible beneficiaries. Such action would also fulfill the administration’s overall
commitment, as set forth in its 2023 Medicare Advantage and Part D Advance Notice, to reduce
disparities and improve health equity in the Medicare program.”

Medicare Advantage

Medicare Advantage plans are a different kind of Medicare service, provided by private companies approved by Medicare. Medicare Advantage plans usually require participants to use doctors within the plan’s network, and a referral is required when a patient sees a specialist.

Medicare Advantage plans may cost more than original Medicare, but they usually have an out-of-pocket cap each year. They often cover services like dental and vision that aren’t covered by Medicare, and may include coverage of prescriptions and transportation to medical facilities. Medicaid Advantage also coordinates care for patients, a function which is important for people who may not have the resources to visit their healthcare providers regularly.

90% of Medicare participants in Puerto Rico use MA plans, as do 97% of dual-eligible users (those who qualify for both Medicaid and Medicare). MA covers nearly half of all health care costs in Puerto Rico.

Funding shortfall

“As you well know from your visits to Puerto Rico, these seniors are generally poorer and have more chronic conditions than the Medicare Advantage population in the states, and yet federal payments for these seniors continues to fall relative to the states,” the congressional letter explained. “MA rates to Puerto Rico that were 32% below the national average in 2015 are now 42% below the national average. That is 37% below the lowest state (Hawaii) and 23% below the next-lowest jurisdiction (the U.S. Virgin Islands).”

The inequitable funding threatens the continuity of care for the individuals who must rely on Medicaid Advantage.

“Americans in Puerto Rico pay the same Medicare payroll tax as mainland citizens,” points out MMAPA, “And yet, Medicare enrollees in Puerto Rico receive the lowest level of federal Medicare spending per enrollee in the country.” The nonprofit organization works to equalize MA funding in Puerto Rico.

“Shockingly, today, MA plans in Puerto Rico are reimbursed approximately $1 billion less
than they were in 2011 – contrary to the trend across every state in the nation,” the letter to Becerra continued. “This lack of adequate funding has been particularly challenging as the island has been forced to navigate hurricanes, earthquakes, a pandemic and other adversities.”

“Failing to close the MA funding gap between Puerto Rico and the states effectively relegates the Puerto Rico health care system to second-tier status,” the congressional representatives concluded. “We therefore ask that in accordance with all applicable laws, rules, and regulations you consider working to address the historically low Medicare Advantage payment rates and their consequences to Puerto Rico’s health system. The time has come to fix these long-standing inequities once and for all.”

Signatories of the letter

The signers of the letter:

  • Jennifer González-Colón (R-PR)
  • Stephanie Murphy (D-FL)
  • Don Young (R-AK)
  • Nydia M. Velásquez (D-NY)
  • Darren Soto (D-FL)
  • Maria Elvira Salazar (R-FL)
  • Don Bacon (R-NE)
  • Mario Diaz-Balart (R-FL)
  • Steven Horsford (D-NV)
  • Thomas R. Suozzi (D-NY)
  • Adriano Espaillat (D-NY)

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