Medicaid agency: PRMP and ASES
Puerto Rico's Medicaid program has two agencies: the Programa Medicaid de Puerto Rico (PRMP), within the Departamento de Salud, determines eligibility, enrolls providers and maintains the State Plan, while the Administración de Seguros de Salud (ASES) runs Plan Vital, the island-wide managed care program that delivers Medicaid and CHIP benefits. CMS's managed care enrollment data for report year 2024 counts 1,109,622 members in Plan Vital's four managed care organizations, and 291,311 dual eligibles in Medicare Platino, the Medicare Advantage plans ASES coordinates with Medicaid. Eligibility is measured against a local poverty level rather than the federal poverty level. Since January 1, 2026, inpatient hospital stays are paid under All Patient Refined Diagnosis Related Groups (APR-DRGs), with base rates and a reimbursement guide published by ASES. ASES is procuring a State Funded Health Plan to cover the locally funded, non-Medicaid population separately from Plan Vital.
Plan Vital is delivered island-wide by four managed care organizations under contracts ASES signed in 2023 and has amended many times since. In report year 2024, Triple-S Salud was the largest plan with 399,402 members, followed by MMM Multi Health (282,920), First Medical Health Plan (277,629) and Plan de Salud Menonita (149,671). ASES sets a minimum payment of $18.00 per member per month for primary care physicians, which the plans must pay; the $18.00 base is paid in full, and ASES's uniform performance metrics adjust only an at-risk portion on top of it. ASES directs the plans through normative and circular letters on coverage, drug lists, rates and reporting.
Puerto Rico operates no Section 1915(c) home and community-based services waivers. Home health and hospice are covered benefits; since May 13, 2026, PRMP has followed a CMS moratorium on enrolling new home health and hospice agencies. Plan Vital covers dental services for residents of long-term care facilities, billed under codes ASES set in July 2026.
Behavioral health is part of each Plan Vital contract: ASES's guidelines for co-locating behavioral health providers in primary medical groups and inpatient settings are an attachment to every MCO contract.
Carved in
Dental care is a Plan Vital benefit delivered by the MCOs, paid under the dental fee schedule attached to each MCO contract. ASES sets the billing codes the plans use, including for dental services in long-term care facilities.
Abarca Health is the pharmacy benefit manager for Plan Vital under a contract with ASES, and ASES maintains a single Preferred Drug List that every MCO follows, changed by normative letter several times a year. ASES has an open procurement for pharmacy benefit manager and rebate aggregator services. High-cost cell and gene therapies, including Casgevy and Lyfgenia for sickle cell disease, are covered under ASES policies outside the plans' risk.
Non-emergency medical transportation is a covered State Plan benefit, including for the Alternative Benefit Plan population.
PRMP runs the Puerto Rico Medicaid Management Information System (PRMMIS), and managed care organizations must submit all encounters and claims to it.
40 agency updates tracked for Puerto Rico. Available with Pro.
See them with ProNo national stories tagged to Puerto Rico yet.
1 active waivers tracked for Puerto Rico. Available with Pro.
See them with Pro3 active solicitations tracked for Puerto Rico. Available with Pro.
See them with Pro145 managed care contracts tracked for Puerto Rico. Available with Pro.
See them with ProPuerto Rico's legislation is not tracked yet: LegiScan does not cover the Legislative Assembly, whose bills are published in Spanish on SUTRA (sutra.oslpr.org).
Get the daily briefing.